MELD is MELD is MELD? Transplant center–level variation in waitlist mortality for candidates with the same biological MELD

Recently, model for end‐stage liver disease (MELD)‐based liver allocation in the United States has been questioned based on concerns that waitlist mortality for a given biologic MELD (bMELD), calculated using laboratory values alone, might be higher at certain centers in certain locations across the country. Therefore, we aimed to quantify the center‐level variation in bMELD‐predicted mortality risk. Using Scientific Registry of Transplant Recipients (SRTR) data from January 2015 to December 2019, we modeled mortality risk in 33 260 adult, first‐time waitlisted candidates from 120 centers using multilevel Poisson regression, adjusting for sex, and time‐varying age and bMELD. We calculated a "MELD correction factor" using each center's random intercept and bMELD coefficient. A MELD correction factor of +1 means that center's candidates have a higher‐than‐average bMELD‐predicted mortality risk equivalent to 1 bMELD point. We found that the “MELD correction factor” median (IQR) was 0.03 (−0.47, 0.52), indicating almost no center‐level variation. The number of centers with “MELD correction factors” within ±0.5 points, and between ±0.5–± 1, ±1.0–±1.5, and ±1.5–±2.0 points was 62, 41, 13, and 4, respectively. No centers had waitlisted candidates with a higher‐than‐average bMELD‐predicted mortality risk beyond ±2 bMELD points. Given that bMELD similarly predicts waitlist mortality at centers across the country, our results support continued MELD‐based prioritization of waitlisted candidates irrespective of center. The authors quantify center‐level variation in the biologic MELD‐predicted mortality risk and find that biologic MELD similarly predicts waitlist mortality across transplant centers in the US, supporting continued MELD‐based prioritization of candidates waitlisted for liver transplant irrespective of transplant center.