Impact of broader geographic allograft sharing on outcomes and cost in smaller lung transplant centers

Haywood, Nathan; Mehaffey, J. Hunter; Kilbourne, Sarah; Mannem, Hannah; Weder, Max; Lau, Christine; Krupnick, Alexander S.; Agarwal, Avinash

Objective On November 24, 2017, Organ Procurement and Transplantation Network implemented a change to lung allocation replacing donor service area with a 250 nautical mile radius around donor hospitals. We sought to evaluate the experience of a small to medium size center following implementation. Methods Patients (47 pre and 54 post) undergoing lung transplantation were identified from institutional database from January 2016 to October 2019. Detailed chart review and analysis of institutional cost data was performed. Univariate analysis was performed to compare eras. Results Similar short-term mortality and primary graft dysfunction were observed between groups. Decreased local donation (68% vs 6%, p < 0.001), increased travel distance (145 vs 235 miles, p = 0.004), travel cost ($8,626 vs $14,482, p < 0.001), and total procurement cost ($60,852 vs. $69,052, p = 0.001) were observed post implementation. We also document an increase in waitlist mortality post-implementation (6.9 vs 31.6 per 100 patient years, p < 0.001). Conclusions Following implementation of the new allocation policy in a small to medium size center, several changes were in accordance with policy intention. However, concerning shifts emerged including increased waitlist mortality and resource utilization. Continued close monitoring of transplant centers stratified by size and location are paramount to maintaining global availability of lung transplantation to all Americans regardless of geographic residence or socioeconomic status. (Word Count: 219/250)