*Purpose: Over the past 4 years, the OPTN has removed Donation Service Area (DSA) and OPTN Region from deceased donor organ allocation with the goal of using consistently applied units of distribution to ensure the most urgent candidates are prioritized, therefore promoting equitable access to transplantation. The aim of this review is to summarize system-wide allocation changes from removing these boundaries from Kidney (KI), Pancreas (PA), Liver (LI), Lung (LU), and Heart (HR) allocation.

*Methods: The OPTN database was analyzed before and after the removal of DSA and OPTN Region from KI, PA, LI, LU and HR allocation to identify system changes in waiting list mortality, transplant rates and organ utilization. The cohort analyzed will vary for each organ due to different implementation dates. KI and PA utilized 6 month, LI 18 months, HR 1 year and LU 3 years pre and post policy change.

*Results: The number of transplants increased after each policy change, consistent with recent trends. There were no statistically significant increases in overall waiting list mortality for any organ. Utilizing the OPTN equity in access methodology there have been minimal changes in equity overall or across DSA. Some medically urgent subpopulations of candidates including LI MELD/PELD 29 or higher, LI status 1s, KI on dialysis longer than 3 years, and LU with LAS greater than or equal to 60 had statistically significant increases in transplant rates (all p-values &lt 0.05). KI-PA, PA and HR Status 1-3 candidates also had increases in their transplant rates; changes were not statistically significant. The distance between the donor hospital and transplant center either remained the same or increased and the impact on costs is unable to be evaluated by the OPTN. Despite the further distances, utilization for thoracic organs did not change (LU 21%, HR 30%) and discard rates for abdominal organs remained stable or improved slightly (LI: pre=9%, post=9%; KI: pre=24%, post=22%; PA: pre= 27%, post=23%).

*Conclusions: There has been some improvement in transplant rates for subpopulations of candidates who are considered of the highest medical urgency. However, there have been minimal changes in overall equity. Future allocation changes include the move to a continuous distribution framework, which will further improve the equity of the system by removing all geographic borders.

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