key: cord-0687756-p0lmgrtm
authors: Agopian, Vatche; Verna, Elizabeth; Goldberg, David
title: Changes in liver transplant center practice in response to COVID‐19: Unmasking dramatic center‐level variability
date: 2020-05-05
journal: Liver Transpl
DOI: 10.1002/lt.25789
sha: 1b10c58014561e183471d45364df8d86a6ef69c3
doc_id: 687756
cord_uid: p0lmgrtm

The COVID‐19 pandemic, caused by the SARS‐CoV‐2 virus, has been devastating to health care delivery in many parts of the US and has had a significant impact on organ transplantation. With shelter‐in‐place orders, outpatient clinics transitioned to telemedicine, and the threat of hospitals being overrun with COVID‐19 patients, liver transplant programs have been faced with the challenge of balancing patient and staff safety while operating in a resource limited environment.

To the editor: The COVID-19 pandemic, caused by the SARS-CoV-2 virus, has been devastating to health care delivery in many parts of the US and has had a significant impact on organ transplantation. With shelter-inplace orders, outpatient clinics transitioned to telemedicine, and the threat of hospitals being overrun with COVID-19 patients, liver transplant programs have been faced with the challenge of balancing patient and staff safety while operating in a resource limited environment.

The transplant community has debated the ethical pillars of access to transplant in this setting, with some contending there may be a significant risk of waitlist mortality among certain patients, arguing for proceeding with transplant despite warnings. 1 Conversely, in areas with the highest prevalence of SARS-CoV-2, there have been concerns about lack of access to critical resources (e.g. intensive care unit [ICU] beds, blood products), risks of perioperative transmission, and logistics of organ procurement. Several societies have recently authored position papers and guidance documents framing how programs could approach these difficult decisions. 2-5 However, no federal regulations have been instituted to enforce changes to current policies. As a result, there may be variability in how individual programs have changed practices, even within the same region. We therefore sought to examine regional-and center-level changes in adult deceased donor liver transplant (DDLT) volume in the month before (February 2020) and after (March 2020) the inception of the US COVID-19 epidemic.

We evaluated center and region reports for donors and recipients each month of 2020 from the publicly available Organ Procurement and Transplantation (OPTN)/United Network for Organ Sharing (UNOS) website 

In 2019, a 21.3% increase in deceased donors from February (n=855) to March (n=1037) resulted in a 21% increase in DDLT nationally (600 to 726, respectively), with a very strong positive correlation (r=0.93) between the change in the number of deceased donors procured in a region and the number of adult DDLT's performed in that region ( Figure 1a ). Conversely, in 2020, an 11% decrease in deceased donors from February (n=1083) to March (n=964) resulted in a 24.7% decrease in adult DDLTs nationally (738 to 556, respectively), with a weak correlation at the regional level (r=0.43; Figure 1b 

This article is protected by copyright. All rights reserved DDLT volume from February to March in 2020 ranged from -7 to +9, with one center performing 18 adult DDLTs in March of 2020.

Regional and center-level variability in LT practice patterns, while not new, has predictably been influenced by knowable factors impacting organ availability, allocation, and recipient and donor selection. However, the unmitigated strain precipitated by COVID-19 could not have been anticipated. Its full impact on our vulnerable transplant population, while undoubtedly grave, is yet wholly unknown. With this report, we take a "first-look" into the early impact of COVID-19 on availability of organs and on regional and center transplant volume. 

This article is protected by copyright. All rights reserved While COVID-19 has had a profound impact on liver transplantation, it has not been restricted to areas with the highest COVID-19 burden. Furthermore, center-level practices have differed dramatically in the same geographic area, including those hit hardest by COVID (e.g., New York). The variability in center behavior cannot be attributed to change in donor organs, allocation policy, or even the local prevalence of COVID-19.

Although hospitals differ in their baseline ICU capacity and their daily ICU census, data suggest that baseline ICU capacity was not associated with adult DDLT volume in March 2020 in the New York City metropolitan area, the area hardest hit by COVID-19 (Pearson correlation coefficient: -0.31 evaluating baseline hospital ICU bed capacity and March 2020 adult DDLT volume). Additionally, widely disparate center-level behavior in the same metropolitan areas (e.g., New York, Los Angeles) suggest that distance between donor hospitals and centers would not explain our results. The differences across centers more likely reflects different allocation and prioritization of hospital resources for COVID-19 relative to liver transplantation, center capabilities to rapidly test and rule out COVID-19 in recipients, and concerns with respect to donors (i.e., accuracy of donor COVID-19 testing), recipients (e.g., impact of COVID-19 in immunosuppressed transplant recipients), and transplant team members (i.e., risks of hospital-acquired COVID-19). Additionally, although data on expedited organ placements are not available, differences in center 'aggressiveness' in accepting organ offers, including those turned down by other centers, likely contributed to differences in center volumes. These numerous factors collectively influence the individual transplant program's perception of risk that drives variable behavior. It is impossible to know which approach is correct. Further data on waitlist outcomes, posttransplant incidence of COVID-19 infection, and survival outcomes in our LT recipients will undoubtedly help inform practical guidance and restore some order to this chaos.

This article is protected by copyright. All rights reserved iii. (**) denotes center with a significant decrease in DDLT volume

Coronavirus disease 2019: Utilizing an ethical framework for rationing absolutely scarce healthcare resources in transplant allocation decisions