*Purpose: On April 30, 2019 the National Liver Review Board (NLRB) was implemented and patients meeting criteria for hepatocellular carcinoma exception points received a score of the median MELD at transplant minus 3 (MMAT-3). On February 4, 2020 liver allocation changed to concentric circles. Approximately one month later the COVID pandemic altered liver transplantation in many regions for a period of time. It is unknown what effect these policy changes had on the wait-list time of patients for liver transplant.

*Methods: We conducted a retrospective cohort study based on data from the Organ Procurement and Transplantation Network from December 2017-June 2020. Mean waiting-time was calculated for the transplants performed each month. An interrupted time-series analysis was used to examine the trend of mean waiting-time for liver transplantation from December 2017 to April 2019 (Pre-NLRB), May 2019 to January 2020 (NLRB-Alone), and February 2020 to June 2020 (Post-Allocation + COVID).

*Results: In the Pre-NLRB era, the mean waiting time for liver transplantation was 240 days. For the NLRB-Alone era the mean waiting time was 209 days, and in the Post-Allocation + COVID era, the mean waiting time was 201 days (Figure 1). However, on interrupted time-series analysis, there was a significant trend in the mean waiting-time for transplant over time. The trend of the mean waiting-time increased in the NLRB-Alone era compared to the Pre-NLRB era (p<0.001). There was a decrease in the trend of mean waiting-time in the Post-Allocation + COVID era (p<0.0001) (Figure 2).

*Conclusions: The NLRB and allocation change for liver transplantation has impacted the waiting time. The trend of the waiting time increased after the NLRB and MMAT-3 policy was implemented. After the allocation change, the trend of the waiting time for liver transplant has had a decreasing trajectory. The allocation change coincided closely with the COVID pandemic, which may have temporarily impacted the waiting-time for transplantation. More data is needed about the long-term impact of allocation changes on wait-list time for liver transplantation.

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