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The Impact of CMS Policy Changes on the Liver Transplant Waiting List
*Natasha H Dolgin, Babak Movahedi, *Paulo NA Martins, Adel Bozorgzadeh, Kate L. Lapane, Fred A. Anderson
UMass Medical School, Worcester, MA

Objective: To explore the impact of policy changes on liver transplant waitlist dynamics, focusing on removals due to illness severity (“too sick to transplant”).
Design: Retrospective cohort.
Setting: U.S. National registry (UNOS/SRTR).
Patients: Adults (≥18 years) added to the liver transplant waiting list between 1998 and 2013. Exclusions: prior liver transplant, exception points for HCC.
Interventions: MELD implementation (2002); CMS Conditions of Participation implementation (2007).
Main Outcome Measures: Waitlist removal due to illness severity (“too sick to transplant”): monthly incidence and slopes (trends) over 3 time periods. Results: Our study sample included 153,430 liver transplant candidates. The overall incidence of waitlist removal due to illness severity increased by 4.7% (6.3% to 11.0%) after implementation of CMS 'Conditions of Participation.' Further, this incidence has been increasing (p<0.001) at almost 7 times the rate during Period 2 (p=0.029). Waitlisted patients were observed to have increasingly higher MELD scores and are older than before. However, the average MELD scores of patients removed due to illness severity has stayed relatively the same over all 3 periods.
Conclusions: Although the MELD allocation system was implemented in order to prioritize the sickest first, incidence in waitlist removal due to illness severity has been sharply increasing and warrant further exploration.
Table 1. Characteristics of Patients Added to the Liver Transplant Waiting List and Patients Removed Due to Illness Severity Over Time.
Period 1:
Prior to MELD Implementation (1998-2002m2)
Period 2:
MELD -to- CMS Interval(2002m3-2006)
Period 3:
After CMS “Conditions of Participation” Implementation(2007-2013m6)
Waitlisted, n(%mortality)51,343 (21.7%)46,078 (16.9%)n=56,009 (12.7%)
Age, mean(SD)46.8 (15.2)51.4 (10.9)53.3 (11.3)
Women (%)40.535.635.1
Last MELD, mean(SD)16.8 (18.9)20.3 (9.9)22.0 (10.5)
Removed due to Illness, n(% of waitlisted)2886 (5.6%)2892 (6.3%)6183 (11.0%)
Age, mean(SD)45.8 (16.5)51.0 (10.9)52.6 (11.5)
Women (%)37.436.236.1
Last MELD, mean(SD)19.3 (9.8)*20.2 (9.9)20.8 (10.4)


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