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Equity-Efficiency Trade-offs Associated With Alternative Approaches to Deceased Donor Kidney Allocation: A Patient-level Simulation

Lookup NU author(s): Dr Charlie Tomson



This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND).


BACKGROUND: The number of patients waiting to receive a kidney transplant outstrips the supply of donor organs. We sought to quantify trade-offs associated with different approaches to deceased donor kidney allocation in terms of quality-adjusted life years (QALYs), costs, and access to transplantation. METHODS: An individual patient simulation model was developed to compare 5 different approaches to kidney allocation, including the 2006 UK National Kidney Allocation Scheme (NKAS) and a QALY maximization approach designed to maximize health gains from a limited supply of donor organs. We used various sources of patient-level data to develop multivariable regression models to predict survival, health state utilities, and costs. We simulated the allocation of kidneys from 2200 deceased donors to a waiting list of 5500 patients and produced estimates of total lifetime costs and QALYs for each allocation scheme. RESULTS: Among patients who received a transplant, the QALY maximization approach generated 48 045 QALYs and cost £681 million, while the 2006 NKAS generated 44 040 QALYs and cost £625 million. When also taking into consideration outcomes for patients who were not prioritized to receive a transplant, the 2006 NKAS produced higher total QALYs and costs and an incremental cost-effectiveness ratio of £110 741/QALY compared with the QALY maximization approach. CONCLUSIONS: Compared with the 2006 NKAS, a QALY maximization approach makes more efficient use of deceased donor kidneys but reduces access to transplantation for older patients and results in greater inequity in the distribution of health gains between patients who receive a transplant and patients who remain on the waiting list.

Publication metadata

Author(s): Li B, Cairns JA, Johnson RJ, Watson CJE, Roderick P, Oniscu GC, Metcalfe W, Bradley JA, Tomson CR, Draper H, Forsythe JL, Dudley C, Ravanan R

Publication type: Article

Publication status: Published

Journal: Transplantation

Year: 2020

Volume: 104

Issue: 4

Pages: 795-803

Print publication date: 01/04/2020

Online publication date: 01/04/2020

Acceptance date: 23/07/2019

Date deposited: 14/04/2020

ISSN (print): 0041-1337

ISSN (electronic): 1534-6080

Publisher: Lippincott Williams & Wilkins


DOI: 10.1097/TP.0000000000002910

PubMed id: 31403554


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Funder referenceFunder name
National Institute for Health Research (NIHR) Programme Grant for Applied Research (RP-PG-0109-10116).