MELD Scores of Liver Transplant Recipients According to Size of Waiting List

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Abstract
In the last decade, considerable controversy has surrounded the allocation of deceased-donor (DD) livers in the United States. Under the old allocation system (used until February 28, 2002) in which priority for transplantation was based primarily on waiting time and subjective measures of urgency, inequalities developed in the procurement and allocation of DD livers. Specifically, there were large disparities in waiting times across geographic regions, as well as difficulties in fairly prioritizing patients for transplantation because the assessment of the severity of illness for patients awaiting transplantation included subjective criteria. As a result, the US Department of Health and Human Services issued a regulation in 1998, referred to as "the final rule," to ensure "that allocation of scarce organs [would] be based on common medical criteria, not accidents of geography."1 The final rule "provide[d] a framework within which the transplant system would operate. The stated principles underlying ‘the Final Rule' include the creation of a ‘level playing field' in organ allocation—that is, organs are allocated based on patients' medical need and less emphasis is placed on keeping organs in the local area where they are procured."1 After issuance of the final rule, many members of the transplant community voiced strong opposition to its implementation. Opponents feared that the final rule would result in the closure of small programs, limit access to transplantation, and decrease organ donation. Consequently, Congress suspended implementation of the final rule for 1 year and asked the Institute of Medicine (IOM) to conduct an independent review to determine the rule's impact on transplantation. The IOM review made 2 principal recommendations relative to allocation of DD livers1