Background: The Model for End Stage Liver Disease (MELD)-based allocation system (2002) transformed liver transplant waitlist mortality by prioritizing the “sickest first.” We examine the extent to which removal of the “sickest” patients on the liver transplant waitlist is associated with the 2007 regulatory CMS policy, “Conditions of Participation (COP).”

Study Design: We used UNOS/SRTR to identify 90,765 US adults (≥18 years of age) on deceased donor liver transplant waiting lists at 102 transplant centers from April 2002 to December 2012. We used interrupted time series regression analysis to quantify national trends in the incidence of candidate delisting due to illness severity (“too sick to transplant” or “medically unsuitable”) pre-post COP implementation (June 28, 2007).

Results: We observed increasing trends in delisting due to illness severity in the setting of comparable demographic and clinical characteristics pre-post COP implementation. The incidence of delisting abruptly increased by 16% at the time of COP implementation and the likelihood of being delisted continued to increase by approximately 3% per quarter thereafter (p<0.001). COP did not impact 1-year post-transplant mortality trends (p=0.38).

Conclusions: CMS “Conditions of Participation” implementation critically altered candidate selection for liver transplantation in 2007. Meaningful improvement in post-transplant survival, at the societal cost of removing increasingly more of the sickest patients, was not observed. Policy-makers and clinicians should consider population-level survival in the design of performance measures and in clinical decision-making.

CITATION INFORMATION: Dolgin N, Movahedi B, Martins P, Bozorgzadeh A. The Impact of CMS Policy on Delisting of "Too Sick" Liver Transplant Candidates. Am J Transplant. 2016;16 (suppl 3).

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