Metrics Subcommittee Data Presenter: John R. Lake, MD 1 Request - PowerPoint PPT Presentation

Allocation Ordering for Simulations • The following allocation orderings were used for all simulations except the current policy scenario. • Adult donors: National status 1B, age 0-17 12. District status 1A National PELD 1. 13. District status 1B National MELD, age 12-17 2. 14. District MELD ≥ 15 National MELD, age 18+ 3. 15. National status 1A 4. National status 1B • Adolescent donors (age 11-17): 5. National M/P ≥ 15 District pediatric status 1A 6. 1. District M/P < 15 District adult status 1A 7. 2. National M/P < 15 District pediatric status 1B 8. 3. District any PELD 4. • Child donors (age 0-10): District MELD >= 15, age 12-17 5. District pediatric status 1A District MELD >= 15, age 18+ 1. 6. National pediatric status 1A (0-11) District MELD < 15, age 12-17 2. 7. District adult status 1A District - MELD < 15, age 18+ 3. 8. District pediatric status 1B National pediatric status 1A 4. 9. District any PELD National adult status 1A 5. 10. District MELD >=15, age 12 to 17 National pediatric status 1B 6. 11. District MELD >= 15 , age 18+ National any PELD 7. 12. District MELD < 15, age 12 to 17 National any MELD, age 12-17 8. 13. District MELD < 15, age 18+ National any MELD, age 18+ 9. 14. National status 1A, age 12-17 10. 23 National status 1A, age 18+ 11.

Proximity Point Parameters: In/ Out District 1. Layout 2. In District 3. Out District • Rectangle: region/district Allocation groupings: Allocation groupings: • Circle: proximity radius 1. A + C ( A has points) 1. A + B + C ( A , B have points) • X : donor center 2. B + D ( B has points) 2. D • A - D : transplant centers 24

Study Population • Analysis based on actual patient data including:  Transplant candidates listed on liver waiting lists as of December 31, 2006  Candidates added to those waiting lists between January 1, 2007 and December 31, 2011  Organs donated between January 1, 2007 and December 31, 2011 Software combines these actual patient data into independent • donor and candidate populations used in each of the multiple LSAM iterations involved in simulating each allocation scenario • 51 DSAs had active liver transplant programs during the sampled time period (2007-2011) 25

Analytic Approach • To assess the impact of proximity points within circles surrounding donor hospitals, we simulated 28 different allocation scenarios with LSAM and compared the results. • Each simulation was repeated 10 times to provide an estimate of variability. • Each of the 10 iterations for each scenario used independent sets of organ and waitlist arrivals and distinct random number seeds. • Each scenario simulated 5 years of transplants. • Allocation MELD/PELD scores were capped at 40 for all simulations. Results reported include a mean estimate and minimum to • maximum values of estimates across all 10 scenarios 26

Outcome Metrics – Disparity and Summative • Disparity Metrics: Variance of median allocation MELD/PELD at transplant across DSAs  Variance in waitlist mortality rates across DSAs  Variance in transplant rates across DSAs  Variance in overall mortality rates for candidates with MELD/PELD of ≥ 20  across DSAs • Summative Metrics: Pretransplant deaths prevented (including waitlist and removal deaths)  Posttransplant deaths prevented  Overall mortality counts and rates  Waitlist mortality counts and rates stratified by MELD/PELD ≥ 35 (including  status 1A and 1B), 29-34, 15-28, < 15 MELD/PELD score at transplant by DSA  27

Outcome Metrics – Cost and Transport • Transport Metrics:  Percentage of transplants that are local (within DSA)  Percentage of transplants that are regional (within district)  Median transport time (hours)  Median transport distance (miles)  Percentage of organs flying • Cost Metrics:  Estimated average transportation cost per transplant • Cost and Transport results will be reviewed during the Logistics and Transportation Ad Hoc Subcommittee and the Finance Ad Hoc Subcommittee presentations 28

Proximity Points Results: Disparity Metrics 29

Figure Conventions • Each figure displays the values for a given metric across the 28 tested scenarios. Each scenario was simulated 10 times. The vertical lines on the plot display the  range of variability extending from the minimum to maximum value for that metric. The point along the line marks the mean value of the metric across the 10  simulated iterations for each of the scenarios. The left most scenario in each plot is the simulation of current policy. To the right  of this are simulations with broader sharing in the current 11 regions, then in 4 districts, and finally in 8 districts. Baseline scenarios with no proximity points are marked by a circular point.  Scenarios with 3 proximity points are marked by a square point.  Scenarios with 5 proximity points are marked by a triangular point.  Scenarios with 150 mile circles are marked by a solid point.  Scenarios with 250 mile circles are marked by a hollow point.  30

Disparity: Variance in median ME LD/ PE LD at transplant 31

Median ME LD/ PE LD at Transplant current policy 11R 3P 150Mi In 8D 3P 150Mi In 4D 3P 150Mi In

Disparity: Variance in pretransplant mortality rates 33

Pretransplant Mortality Rate current policy 11R 3P 150Mi In 8D 3P 150Mi In 4D 3P 150Mi In

Disparity: Variance in transplant rates 35

Transplant Rate current policy 11R 3P 150Mi In 8D 3P 150Mi In 4D 3P 150Mi In

Disparity: Variance in overall* mortality rates once candidates reach a ME LD/ PE LD of 20 * Includes both pre- and posttransplant mortality 37

Overall Mortality Rate current policy 11R 3P 150Mi In 8D 3P 150Mi In 4D 3P 150Mi In

Proximity Points Results: Summative Metrics

Summative: Pretransplant deaths prevented per year 40

Summative: Posttransplant deaths prevented per year 41

Summative: Overall mortality rates 42

Summative: Waitlist mortality rates for MELD/PELD ≥ 35 43

Summative: Waitlist mortality rates for ME LD/ PE LD 29-34 Very little estimated difference between scenarios is seen in this figure. Waitlist mortality rates for M/P 15-28 and < 15 show a similar pattern, with no appreciable differences 44 between scenarios.

Additional metrics: Transplant Rates 45

Subgroup Analyses: E ffects on Vulnerable Populations • Pediatric patients have similar outcomes across the simulated scenarios in most cases. Exceptions:  Transplant rates increase in 4- and 8-district in-district scenarios  Transport distances and times increase in 4- and 8-district scenarios • Racial/ethnic subgroups have similar outcomes across the simulated scenarios in most cases. Exceptions:  Transplant rates decreased the most for Caucasian patients in redistricted scenarios  Transplant rates decrease very slightly for African-American patients in redistricted scenarios  Transplant rates increase for Hispanic and Asian patients in redistricted scenarios 46

Proximity Points Summary Across the wide range of scenarios and metrics studied, a few overall trends stood out: • The number of distribution units (11 regions, 4 or 8 districts) and the sharing configuration for proximity circles (in-district or out-district) had the largest effects on variation between scenarios. • Out-district proximity circles were similar to each other across 11 region, 4-district, and 8-district scenarios. This may indicate that out-district circles perform less like regional allocation and more like concentric circle allocation. • Largest decreases in disparity metrics were seen among 4-district baseline and in- district circle scenarios, followed by 8-district baseline and in-district circle scenarios. Out-district circle scenarios decreased disparity metrics compared to current policy, but not as much as 4- and 8-district baseline and in-district scenarios. • Very little variation in mortality rates was observed across any of the scenarios, with the exception of the MELD ≥ 35 group where waitlist mortality decreased slightly in the 4- and 8-district scenarios. • Adding proximity circles to 4- and 8-district scenarios increased the local transplant percentage while decreasing transport times, distances, and flying percentages (shown in transport presentation) 47

Q & A

Supplemental Slides: Data Request 1.1 49

Actual donors/ WL candidates ME LD/ PE LD > 15 52 DSAs 11 Regions 8 Districts 4 Districts 50

E ligible deaths / WL candidates lab ME LD/ PE LD > 15 52 DSAs 11 Regions 8 Districts 4 Districts 51

E ligible deaths / WL candidates ME LD/ PE LD > 24 52 DSAs 11 Regions 8 Districts 4 Districts 52

Supplemental Slides: Data Request 1.2 53

Simulated Scenarios Run Number Candidate Run Number Candidate Distribution Radius Distribution Radius Number of Points Designation Number of Points Designation Out of 1 11 Regions None None None 15 4 Districts 3 250 district 2 4 Districts None None None 16 4 Districts 5 150 In district Out of 3 8 Districts None None None 17 4 Districts 5 150 district 4 11 Regions 3 150 In district 18 4 Districts 5 250 In district Out of Out of 5 11 Regions 3 150 19 4 Districts 5 250 district district 6 11 Regions 3 250 In district 20 8 Districts 3 150 In district Out of Out of 7 11 Regions 3 250 21 8 Districts 3 150 district district 22 8 Districts 3 250 In district 8 11 Regions 5 150 In district Out of Out of 23 8 Districts 3 250 9 11 Regions 5 150 district district 24 8 Districts 5 150 In district 10 11 Regions 5 250 In district Out of Out of 25 8 Districts 5 150 11 11 Regions 5 250 district district 26 8 Districts 5 250 In district 12 4 Districts 3 150 In district Out of Out of 27 8 Districts 5 250 13 4 Districts 3 150 district district Current 28 None None None 14 4 Districts 3 250 In district 54 system

LSAM Strengths and Limitations Limitations Strengths • Predicts direction of change • Draws on real transplant between alternatives, not data necessarily the magnitude of change • Simulates up to 5 years • Cannot account for changes • Multivariable acceptance in listing or acceptance behavior and survival models • Cannot predict outcomes on • Can compare multiple a center-by-center basis allocation and distribution • Most recent input data files systems use data through 2011 55

Summative: Overall mortality counts per year 56

Summative: Annual waitlist mortality counts for LD ≥ 35 ME LD/ PE 57

Summative: Annual waitlist mortality counts for ME LD/ PE LD 29-34 58

Summative: Annual waitlist mortality counts for ME LD/ PE LD <15 59

Summative: Waitlist mortality rates for ME LD/ PE LD 15-28 60

Summative: Waitlist mortality rates for ME LD/ PE LD <15 61

Additional Metrics: Transplant Counts 62

Additional Metrics: Pretransplant Mortality Counts 63

Additional Metrics: Pretransplant Mortality Rates 64

Disparity Metrics Table Variance in median MELD Variance in pretransplant mortality rates Variance in transplant rates Variance in mortality rates after at transplant MELD 20 Current 6.2 (5.5-6.9) 0.00058 (0.00043-0.00073) 0.116 (0.105-0.128) 0.00035 (0.00024-0.00052) 11 Regions 8.2 (7.4-9.1) 0.00049 (0.00043-0.00058) 0.1 (0.09-0.111) 0.00031 (0.00021-0.0004) 11R 3P 150Mi In 8.3 (7.5-9.7) 0.00052 (0.0004-0.00063) 0.106 (0.09-0.13) 0.00032 (0.00019-0.00059) 11R 3P 250Mi In 8.3 (7.2-9.3) 0.00053 (0.0004-0.00068) 0.108 (0.092-0.124) 0.00034 (0.00022-0.00058) 11R 5P 150Mi In 7.7 (6.9-8.6) 0.00055 (0.00046-0.00063) 0.107 (0.091-0.128) 0.00034 (0.00024-0.00074) 11R 5P 250Mi In 7.9 (6.8-8.9) 0.00051 (0.00042-0.00067) 0.113 (0.1-0.126) 0.00038 (0.00025-0.0007) 11R 3P 150Mi Out 4.2 (3.8-4.6) 0.00061 (0.00048-0.0007) 0.062 (0.051-0.071) 0.00031 (0.0002-0.00041) 11R 3P 250Mi Out 3.8 (3.5-4.7) 0.00061 (0.00048-0.0007) 0.062 (0.053-0.069) 0.0003 (0.00016-0.00056) 11R 5P 150Mi Out 4.1 (3.6-4.6) 0.00061 (0.0005-0.00075) 0.062 (0.052-0.068) 0.0003 (0.00021-0.00043) 11R 5P 250Mi Out 3.8 (3.3-4.6) 0.00059 (0.00045-0.0007) 0.061 (0.051-0.07) 0.00031 (0.00021-0.00044) 4 Districts 2.1 (1.6-2.7) 0.0004 (0.00031-0.00047) 0.024 (0.021-0.029) 0.00023 (0.00018-0.00029) 4D 3P 150Mi In 2.1 (1.6-2.7) 0.00042 (0.00031-0.0005) 0.027 (0.023-0.032) 0.00025 (0.00014-0.00032) 4D 3P 250Mi In 2.1 (1.5-2.5) 0.00043 (0.00034-0.00056) 0.029 (0.025-0.035) 0.00024 (0.00016-0.00048) 4D 5P 150Mi In 2.3 (1.8-2.8) 0.00046 (0.00039-0.00057) 0.031 (0.026-0.036) 0.00026 (0.00014-0.00047) 4D 5P 250Mi In 2.4 (1.9-3.2) 0.00047 (0.00039-0.00057) 0.032 (0.027-0.038) 0.00026 (0.00014-0.0004) 4D 3P 150Mi Out 4 (3.6-4.6) 0.0006 (0.00045-0.00078) 0.06 (0.046-0.072) 0.00031 (0.00022-0.00045) 4D 3P 250Mi Out 3.7 (3.1-4.5) 0.00057 (0.00049-0.00069) 0.063 (0.054-0.076) 0.00033 (0.00019-0.00066) 4D 5P 150Mi Out 4.1 (3.4-4.7) 0.00061 (0.00047-0.00074) 0.062 (0.052-0.07) 0.00027 (0.00021-0.00038) 4D 5P 250Mi Out 3.7 (3.2-4.2) 0.00058 (0.00049-0.00067) 0.06 (0.053-0.069) 0.00027 (0.00018-0.00044) 8 Districts 2.8 (2.1-3.5) 0.00047 (0.00036-0.00058) 0.027 (0.021-0.031) 0.00029 (0.00018-0.0004) 8D 3P 150Mi In 2.9 (2-3.6) 0.00046 (0.00036-0.00057) 0.029 (0.025-0.033) 0.00026 (0.00019-0.00032) 8D 3P 250Mi In 3 (2.1-3.6) 0.00046 (0.00036-0.00054) 0.03 (0.025-0.034) 0.00026 (0.00015-0.00051) 8D 5P 150Mi In 3 (2.2-3.8) 0.00048 (0.0004-0.00059) 0.032 (0.025-0.04) 0.0003 (0.00016-0.00039) 8D 5P 250Mi In 3 (2.1-3.9) 0.00051 (0.00041-0.00067) 0.033 (0.028-0.036) 0.00031 (0.00023-0.00062) 8D 3P 150Mi Out 4.1 (3.6-5) 0.00061 (0.0005-0.00074) 0.059 (0.049-0.067) 0.0003 (0.00023-0.00051) 8D 3P 250Mi Out 3.8 (3.2-4.9) 0.00058 (0.00046-0.00084) 0.065 (0.055-0.075) 0.00028 (0.00022-0.00039) 8D 5P 150Mi Out 4.1 (3.6-4.8) 0.00062 (0.00046-0.00074) 0.061 (0.047-0.072) 0.00028 (0.00019-0.00044) 8D 5P 250Mi Out 3.6 (3-4.5) 0.00058 (0.00045-0.00069) 0.061 (0.054-0.069) 0.0003 (0.00016-0.00078) 65

Summative Metrics Table Pretransplant deaths per year Posttransplant deaths per year Overall deaths per year Overall death rates per patient-year prevented prevented 11 Regions -4.8 (-27.8-12.6) 4.7 (-18.4-32.6) 3608.1 (3567.8-3658.4) 0.1 (0.1-0.1) 11R 3P 150Mi In 4.9 (-12.4-26) 0.6 (-25.2-32.4) 3608.2 (3565.6-3652.8) 0.1 (0.1-0.1) 11R 3P 150Mi Out 31.9 (17.2-48.2) -53.3 (-79.8--40.8) 3602.6 (3558.4-3652.8) 0.1 (0.1-0.1) 11R 3P 250Mi In 5.1 (-13.2-24) -0.1 (-33.4-20) 3603.1 (3571.8-3637.2) 0.1 (0.1-0.1) 11R 3P 250Mi Out 17.9 (-1.2-27.2) -39.2 (-63.4--1.8) 3601.1 (3563.4-3648.8) 0.1 (0.1-0.1) 11R 5P 150Mi In 4.1 (-12-19.2) 2.9 (-21.2-21) 3613.5 (3578.6-3644) 0.1 (0.1-0.1) 11R 5P 150Mi Out 32.7 (21-53.6) -49.7 (-75--32.2) 3629.5 (3600-3672.8) 0.1 (0.1-0.1) 11R 5P 250Mi In -4.3 (-26.8-15.2) -1.1 (-20.8-13) 3629.4 (3581.2-3680.4) 0.1 (0.1-0.1) 11R 5P 250Mi Out 19.6 (6.8-32.2) -37.3 (-66.6--8.8) 3625.1 (3592.4-3682.8) 0.1 (0.1-0.1) 4 Districts 118.8 (100.4-134.6) 1.6 (-42.6-29) 3625.8 (3595-3656.4) 0.1 (0.1-0.1) 4D 3P 150Mi In 116.4 (97.2-133.6) -11.5 (-41.8-23.4) 3487.8 (3468.2-3507.4) 0.1 (0.1-0.1) 4D 3P 150Mi Out 39.7 (18.8-59.6) -33 (-54--17) 3503.2 (3471.2-3537.2) 0.1 (0.1-0.1) 4D 3P 250Mi In 113.7 (97-132) -13.3 (-38.8-6.6) 3507.7 (3469.4-3540.6) 0.1 (0.1-0.1) 4D 3P 250Mi Out 17.7 (-4-34.8) -14.2 (-38.8-11.4) 3508.2 (3483.8-3561.4) 0.1 (0.1-0.1) 4D 5P 150Mi In 103.1 (81.6-117.8) -3.2 (-19.6-14.4) 3520.6 (3482.8-3554.4) 0.1 (0.1-0.1) 4D 5P 150Mi Out 42.4 (27.8-59.2) -44.9 (-61.2--29.8) 3601.3 (3575.6-3637.6) 0.1 (0.1-0.1) 4D 5P 250Mi In 97.9 (88-111) -10.3 (-30.4-5.8) 3604.6 (3562.2-3654.8) 0.1 (0.1-0.1) 4D 5P 250Mi Out 16.2 (-1.8-33) -6.3 (-24.6-10.2) 3610.6 (3582.2-3643.2) 0.1 (0.1-0.1) 8 Districts 59.8 (39.8-86.6) 1.2 (-17.8-27.6) 3598.2 (3565-3649.4) 0.1 (0.1-0.1) 8D 3P 150Mi In 55.4 (35-74.2) -3.3 (-22.4-18.4) 3547 (3523.6-3567.2) 0.1 (0.1-0.1) 8D 3P 150Mi Out 38.3 (15.8-54.4) -46.3 (-75.6--29.4) 3556 (3525.4-3589.6) 0.1 (0.1-0.1) 8D 3P 250Mi In 51.6 (30.2-63.8) 5.4 (-19-25.4) 3551.1 (3528-3595.2) 0.1 (0.1-0.1) 8D 3P 250Mi Out 21.9 (-1.8-43.6) -28.7 (-52.6-4.2) 3562.9 (3538.2-3604.4) 0.1 (0.1-0.1) 8D 5P 150Mi In 53.5 (36.2-69.2) -8.3 (-23.6-7) 3558.2 (3521.8-3599) 0.1 (0.1-0.1) 8D 5P 150Mi Out 37.3 (9.8-60.4) -48.1 (-78.8--33.8) 3616.1 (3585.4-3668.6) 0.1 (0.1-0.1) 8D 5P 250Mi In 50.6 (35.8-68.8) -0.7 (-30-27.8) 3614.9 (3590-3645.2) 0.1 (0.1-0.1) 8D 5P 250Mi Out 17.1 (2.2-30) -23.7 (-38.2--12.8) 3618.9 (3590.8-3684.4) 0.1 (0.1-0.1) Current 0 (0-0) 0 (0-0) 3614.7 (3596.6-3655.6) 0.1 (0.1-0.1) 66

Mortality Counts by ME LD Category Table ≥35 29-34 15-28 <15 Current 93.8 (85-100.4) 38.6 (34.6-46.4) 267.8 (257.4-278) 279.7 (270.8-284.8) 11 Regions 89.4 (83-95.2) 33.1 (29.8-38.8) 275.9 (267.6-288.6) 283.3 (278.2-288.6) 11R 3P 150Mi In 88.7 (80.4-98.4) 34.8 (31.6-41.2) 274.1 (263.8-285.6) 283.3 (276.2-289) 11R 3P 250Mi In 89 (84.6-94.2) 32.9 (28.2-38.8) 275.1 (263.4-292) 282.5 (275.4-290) 11R 5P 150Mi In 90.3 (81-98) 33.8 (30.6-38.2) 273.8 (267-288.6) 281.8 (274-287.6) 11R 5P 250Mi In 91.1 (84.6-98.2) 33.9 (31-40) 274.5 (261.4-290) 282.8 (274.8-289.2) 11R 3P 150Mi Out 79.7 (75-84.4) 33.1 (27.6-38.6) 273.1 (261.4-286) 279.7 (271.4-285.8) 11R 3P 250Mi Out 79.2 (74-85.6) 31.5 (25.4-36.8) 276.7 (266-289) 282.1 (275.6-285.8) 11R 5P 150Mi Out 78.3 (71.4-84.2) 34.6 (29-41.4) 271.9 (262.4-285.6) 279.6 (273.2-285) 11R 5P 250Mi Out 80.5 (73.6-88) 31 (23.4-37.2) 277.1 (267.8-293.6) 281.5 (273-288.4) 4 Districts 48.1 (44.4-52) 22.6 (19-27.6) 277.3 (266.6-288.6) 284.1 (276-291) 4D 3P 150Mi In 49.2 (45.8-52) 22.6 (18.4-25.6) 280 (271.6-291.6) 284.3 (275.6-292.2) 4D 3P 250Mi In 48.2 (43.2-52.2) 22.8 (17.6-26.6) 280.7 (272.6-291.6) 284 (276.2-289) 4D 5P 150Mi In 49.7 (45.2-54.2) 23.9 (20.6-30.8) 279.6 (273-291.6) 284.6 (276.6-291.6) 4D 5P 250Mi In 49.6 (44.6-58) 25.1 (20.6-30.4) 281.5 (271.6-294) 284.1 (276.2-289) 4D 3P 150Mi Out 78.5 (72.2-82.6) 33.6 (30.2-40) 272.9 (263-281.4) 279.6 (272.6-285.6) 4D 3P 250Mi Out 79.6 (72.8-88.6) 31.7 (27.4-37.2) 276.5 (263.2-286.2) 282.8 (276.6-289.2) 4D 5P 150Mi Out 78.8 (73.4-86) 34.1 (27.6-41.2) 271.7 (262.4-285) 280.1 (272.4-287) 4D 5P 250Mi Out 82 (74.2-88.2) 31.2 (26.8-34.8) 276.3 (266.2-285.8) 282.9 (275.6-289) 8 Districts 71.1 (65.2-76) 27.1 (23.4-32) 276.1 (266.6-287.8) 282.8 (275-289.2) 8D 3P 150Mi In 72.6 (67.6-77.2) 28.6 (24.2-34.6) 276.5 (267-288.2) 282.4 (273.8-288) 8D 3P 250Mi In 72.1 (67.4-76) 27.9 (24-34.6) 277.6 (270.2-289.4) 282.5 (276.8-289.8) 8D 5P 150Mi In 72 (67.6-79.8) 29.5 (23.8-35.6) 275.3 (267-290.8) 282.6 (275.2-288.4) 8D 5P 250Mi In 72.5 (67.2-77.4) 29.5 (25-33.6) 277.3 (267.2-286.4) 281.7 (273.2-287.4) 8D 3P 150Mi Out 78.2 (71.4-85.4) 33.6 (29.2-40.2) 272.1 (262.6-282.2) 280.9 (272.4-285.8) 8D 3P 250Mi Out 79.1 (74.4-85.2) 31.2 (26.6-37) 274.7 (268.8-284.8) 282.7 (274.8-287.6) 8D 5P 150Mi Out 79.7 (75-86.4) 33.8 (30.6-41.2) 273.6 (265.4-285.4) 279.1 (271.4-286) 8D 5P 250Mi Out 81.3 (73.8-86) 32.4 (25.6-37.8) 277.2 (269-291) 282.9 (277.8-290.2) 67

Waitlist Mortality Rates by ME LD Category Table 35+ 29-34 15-28 <15 Current 1.249 (1.073-1.412) 0.23 (0.211-0.258) 0.063 (0.06-0.065) 0.028 (0.027-0.028) 11 Regions 1.261 (1.118-1.398) 0.265 (0.229-0.329) 0.061 (0.06-0.064) 0.028 (0.027-0.028) 11R 3P 150Mi In 1.247 (1.115-1.324) 0.269 (0.241-0.304) 0.062 (0.06-0.064) 0.028 (0.027-0.028) 11R 3P 250Mi In 1.249 (1.096-1.374) 0.257 (0.234-0.315) 0.062 (0.059-0.064) 0.028 (0.027-0.028) 11R 5P 150Mi In 1.262 (1.075-1.397) 0.254 (0.23-0.297) 0.062 (0.061-0.063) 0.028 (0.027-0.028) 11R 5P 250Mi In 1.286 (1.132-1.428) 0.259 (0.232-0.294) 0.062 (0.059-0.064) 0.028 (0.027-0.028) 11R 3P 150Mi Out 1.279 (1.17-1.418) 0.264 (0.224-0.318) 0.062 (0.06-0.063) 0.027 (0.027-0.028) 11R 3P 250Mi Out 1.222 (1.09-1.323) 0.275 (0.224-0.331) 0.061 (0.059-0.063) 0.027 (0.027-0.028) 11R 5P 150Mi Out 1.256 (1.153-1.374) 0.274 (0.232-0.332) 0.062 (0.06-0.063) 0.027 (0.027-0.028) 11R 5P 250Mi Out 1.265 (1.108-1.401) 0.271 (0.21-0.348) 0.061 (0.059-0.063) 0.027 (0.027-0.028) 4 Districts 1.088 (0.955-1.211) 0.295 (0.26-0.334) 0.055 (0.054-0.057) 0.027 (0.027-0.028) 4D 3P 150Mi In 1.112 (1.022-1.19) 0.284 (0.244-0.327) 0.057 (0.056-0.059) 0.027 (0.027-0.028) 4D 3P 250Mi In 1.072 (0.954-1.183) 0.282 (0.228-0.332) 0.057 (0.056-0.06) 0.027 (0.027-0.028) 4D 5P 150Mi In 1.091 (0.997-1.225) 0.28 (0.241-0.339) 0.058 (0.057-0.06) 0.028 (0.027-0.028) 4D 5P 250Mi In 1.083 (0.938-1.242) 0.287 (0.25-0.356) 0.058 (0.057-0.061) 0.027 (0.027-0.028) 4D 3P 150Mi Out 1.24 (1.07-1.403) 0.267 (0.237-0.34) 0.062 (0.06-0.064) 0.027 (0.027-0.028) 4D 3P 250Mi Out 1.238 (1.047-1.352) 0.277 (0.239-0.316) 0.061 (0.058-0.063) 0.027 (0.027-0.028) 4D 5P 150Mi Out 1.267 (1.176-1.414) 0.271 (0.225-0.324) 0.062 (0.06-0.063) 0.027 (0.027-0.028) 4D 5P 250Mi Out 1.287 (1.178-1.363) 0.273 (0.24-0.314) 0.061 (0.059-0.064) 0.027 (0.027-0.028) 8 Districts 1.178 (1.099-1.274) 0.28 (0.244-0.336) 0.058 (0.057-0.06) 0.027 (0.027-0.028) 8D 3P 150Mi In 1.202 (1.092-1.383) 0.289 (0.246-0.327) 0.06 (0.058-0.061) 0.027 (0.027-0.028) 8D 3P 250Mi In 1.201 (1.069-1.259) 0.281 (0.252-0.321) 0.06 (0.058-0.061) 0.027 (0.027-0.028) 8D 5P 150Mi In 1.185 (1.083-1.328) 0.282 (0.231-0.321) 0.06 (0.059-0.063) 0.027 (0.027-0.028) 8D 5P 250Mi In 1.208 (1.071-1.321) 0.285 (0.248-0.333) 0.06 (0.058-0.062) 0.027 (0.027-0.028) 8D 3P 150Mi Out 1.267 (1.122-1.389) 0.266 (0.23-0.304) 0.062 (0.06-0.064) 0.028 (0.027-0.028) 8D 3P 250Mi Out 1.236 (1.148-1.333) 0.272 (0.228-0.337) 0.061 (0.06-0.062) 0.027 (0.027-0.028) 8D 5P 150Mi Out 1.276 (1.16-1.468) 0.268 (0.237-0.308) 0.062 (0.061-0.064) 0.027 (0.027-0.028) 8D 5P 250Mi Out 1.261 (1.071-1.42) 0.287 (0.221-0.358) 0.061 (0.06-0.063) 0.027 (0.027-0.028) 68

Summary: 11 Region Broader Sharing • Disparity metrics:  Variance in median MELD at transplant increased for baseline and in- district circles scenarios but decreased for out-district circles as compared to current policy  Variance in transplant rates did not differ from current policy in baseline and in-district scenarios, decreased in out-district scenarios  Variance in waitlist mortality and overall mortality did not appreciably differ from current policy • Summative metrics:  Mortality metrics were broadly similar to the simulation of current policy across 11 region scenarios Transport metrics: •  11 region scenarios overall showed the smallest increase in median transport time, flying percentage, and transport cost compared with current policy  11 region out-district scenarios did not differ from 4- or 8-district out- district circle scenarios in transport patterns 69

Summary: 4 District Broader Sharing • Disparity metrics: 4-district baseline and in-district scenarios showed largest projected reduction of all  scenarios (more than 2 times) in variance in median MELD at transplant from current policy, largest reduction in variance in waitlist mortality and transplant rates. 4-district out-district circle scenarios also showed reductions in these disparity metrics  compared to the current system, but less so than other 4-district scenarios. • Summative metrics: 4-district baseline and in-district circle scenarios had greatest impact of all scenarios on  pretransplant deaths prevented per year, posttransplant deaths prevented per year in the same range as current policy, and greatest decrease in overall mortality and waitlist mortality counts and rates per year. 4-district out-district circle scenarios did not appreciably differ from current policy, 11  region, and 8-district out-district circle scenarios • Transport metrics: 4-district baseline scenario showed highest transport time, distance, and highest percent  flying. 4-district in-district circle scenarios reduced this effect. 4-district out-district circle scenarios did not differ from 11 region or 8-district  out-district circle scenarios in transport patterns 70

Summary: 8 District Broader Sharing • Metrics for 8-district scenarios fell between the 11-region and 4-district results in most cases • Disparity metrics: Variance in median MELD at transplant decreased by a factor of nearly 2 for 8-district baseline  and in-district circle scenarios (though not as far as 4-district baseline and in-district scenarios). Variance in transplant rates was similar to 4-district scenarios 8-district out-district circle scenarios also showed reductions in these disparity metrics  compared to the current system, but less so than other 8-district scenarios • Summative metrics: 8-district scenarios showed some advantage over current policy in pretransplant deaths  prevented per year. For posttransplant deaths prevented per year, 8-district baseline and in-district scenarios did  not differ from current policy, out-district scenarios decreased prevented deaths For overall mortality, 8-district baseline and in-district scenarios showed a decrease, but out-  district scenarios did not appreciably differ from current policy • Transport metrics: 8-district baseline and in-district scenarios had slightly less transport time, distance, and  percent flying than 4-district in-district scenarios. 8-district out-district scenarios did not differ from 11 region or 4-district out-district scenarios. 71

Supplemental Slides: Subgroup Analysis

Subgroup Analysis: Transplant Counts (Pediatrics)

Subgroup Analysis: Transplant Counts (Gender)

Subgroup Analysis: Transplant Counts (Race/ E thnicity)

Subgroup Analysis: Transplant Rates (Pediatrics)

Subgroup Analysis: Transplant Rates (Gender)

Subgroup Analysis: Transplant Rates (Race/ E thnicity)

Subgroup Analysis: Pretransplant Deaths Prevented (Pediatrics)

Subgroup Analysis: Pretransplant Deaths Prevented (Gender)

Subgroup Analysis: Pretransplant Deaths Prevented (Race/ E thnicity)

Subgroup Analysis: Posttransplant Deaths Prevented (Pediatrics)

Subgroup Analysis: Posttransplant Deaths Prevented (Gender)

Subgroup Analysis: Posttransplant Deaths Prevented (Race/ E thnicity)

Subgroup Analysis: Overall Mortality Counts (Pediatric)

Subgroup Analysis: Overall Mortality Counts (Gender)

Subgroup Analysis: Overall Mortality Counts (Race/ E thnicity)

Subgroup Analysis: Overall Mortality Rates (Pediatrics)

Subgroup Analysis: Overall Mortality Rates (Gender)

Subgroup Analysis: Overall Death Rates (Race/ E thnicity)

Subgroup Analysis: Median Transport Time (Pediatrics)

Subgroup Analysis: Median Transport Time (Gender)

Subgroup Analysis: Median Transport Time (Race/ E thnicity)

Subgroup Analysis: Median Transport Distance (Pediatrics)

Subgroup Analysis: Median Transport Distance (Pediatrics)

Subgroup Analysis: Median Transport Distance (Race/ E thnicity)

Subgroup Analysis: Pretransplant Mortality Counts (Pediatrics)

Subgroup Analysis: Pretransplant Mortality Counts (Gender)

Subgroup Analysis: Pretransplant Mortality Counts (Race/ E thnicity)

Subgroup Analysis: Pretransplant Mortality Rates (Pediatrics)