UCLA

Since its evolution, organ allocation in liver transplantation has been based upon the ‘rule of rescue’, where patients are prioritized for transplantation based on their medical need and acuity. As the system has evolved, arbitrary geographic boundaries and variations in the supply and demand for organs have created a system marked by geographic inequities. Share 35, the most recent of the United Network for Organ Sharing liver transplant allocation policies, aimed to reduce these inequities at the regional level by instituting intra-regional organ sharing for the sickest patients (defined as allocation Model for End Stage Liver Disease (MELD) scores of ≥35). Similar to other organ allocation policies, evaluations of Share 35 have been limited to traditional markers of quality in transplantation, namely pre- and post-transplant survival. Acknowledging that these policies have far reaching effects, beyond patient survival alone, this dissertation assessed the potential impacts of the Share 35 policy on both inpatient utilization and post-transplant disability. Utilizing a novel database linkage between six state inpatient datasets (Agency for Healthcare Research and Quality – Healthcare Cost and Utilization Project and California Office for Statewide Hospital Planning and Development) and the liver transplant registry, a stepwise analysis of the potential causal pathways through which the policy may have affected each outcome was completed. Prior to assessing the impact of Share 35 directly, potential drivers of post-transplant utilization prior to policy implementation were evaluated, indicating that both patient acuity at the time of transplant and donor organ quality are strongly associated with post-transplantation inpatient utilization within the six months following transplantation. These findings build upon previous single-institution studies and prior reports which were limited to only 30-days of post-transplant follow-up. This dissertation then assesses Share 35 and demonstrates that by increasing organ availability to patients in the greatest need of transplantation, Share 35 resulted in substantial decreases in post-transplant inpatient utilization as well as modest improvements in post-transplant disability. These findings suggest that continued efforts to expand organ sharing across geographic boundaries will lead to improved patient outcomes and reduced health resource utilization.