*Purpose: In November 2017, the lung allocation policy was challenged in court due to concern that candidates living in New York City were being disadvantaged compared to neighboring DSAs. After urgent review, the OPTN/UNOS Executive Committee decided to abandon sharing at the DSA level and implemented a 250 nautical mile (NM) circle as the first unit of allocation. We sought to quantify geographic disparities in lung transplant (LT) rates in the eras before and after the 250 NM circle.

*Methods: We estimated LT rates per active person-year on the waitlist using multilevel Poisson regression and empirical Bayes methods in the eras before and after the policy change. We calculated the median incidence rate ratio (MIRR) which summarizes the between-transplant center variation in LT rates and is a measure of overall geographic disparity. MIRR can be interpreted as the increase in LT rate a candidate could expect if they moved or listed at another transplant center with a higher transplant rate.

*Results: The MIRR before the 250 NM circle was 2.07, and it increased to 2.23 after the policy change. So a candidate could on average increase their LT rate more than two-fold by listing at another transplant center before and after the 250 NM circle. By comparison, an increase in LAS category from 42-50 to 50-100 after the 250 NM circle was associated with a 2.39-fold increase in LT rate (Table 2). There was no clear pattern of change in LT rate by OPTN region with 39 centers experiencing an increase and 34 centers experiencing a decrease (Figure 1B).

*Conclusions: The 250 NM circle was implemented to comply with the Final Rule, but it was not able to eliminate or even reduce geographic disparities in lung transplantation.

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