*Purpose: Survival benefit of liver transplantation is strongly correlated with Model for End Stage Liver Disease (MELD) score at transplant. Variability in organ supply across the United States has led to between-center variation in the mean MELD at transplant. We aimed to quantify the impact of the geographic variation in MELD at transplant on the efficiency of the allocation system.

*Methods: Data on all adults aged ≥18 yrs listed for liver transplant from 2009-2013 were collected from the Scientific Registry of Transplant Recipients (SRTR). The time period was chosen to ensure 5 years of follow-up post listing and end prior to Share 35 implementation. Candidates listed for acute liver failure, multiorgan transplant, or at low-volume centers (≤10 transplants) were excluded. We calculated 5-year survival benefit of liver transplantation – the difference between post-transplant and wait-list survival at 5 years after transplantation – using a mixed-effects Cox proportional hazards model with transplant as a time-dependent covariate. Each transplant center’s mean survival benefit was estimated using the observed MELD score distribution at the center.

*Results: Of 51,013 candidates listed at 114 centers, 26,734 (52.4%) underwent liver transplantation. Transplant was associated with a mean absolute 5-year survival benefit of 21% (IQR -9 to 55), increasing from 49% (IQR 3-87) without transplant to 71% (IQR 67-77) with transplant. 5-year survival benefit of transplantation increased by 13.05% (95% CI 13.0-13.1) with each 5-point increase in MELD (Fig 1). Survival benefit from transplant was negative for MELD<13.07. Mean MELD at transplant was 21 and varied from 17 to 27 by center. Mean survival benefit by center ranged from 5.2% to 35.2% (IQR 17.6-21.7) (Fig 2).

*Conclusions: Mean MELD score at time of transplant varies significantly between centers. Additionally, survival benefit of liver transplantation is correlated with MELD score at transplant. Adjusting regional organ distribution policy to promote transplantation at a more uniform MELD would likely decrease this variability and increase total survival benefit of liver transplantation.

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