Is multiple listing for a transplant beneficial if the two transplant centers are only 4 hours apart?

Multiple Listing for Transplant Centers 4 Hours Apart

Multiple listing at transplant centers only 4 hours apart offers minimal to no meaningful advantage and may be ethically problematic, as the geographic proximity places both centers within the same or overlapping organ allocation zones, negating the primary benefit of multiple listing—access to different donor pools with varying wait times.

Understanding Multiple Listing and Geographic Allocation

The rationale for multiple listing centers on accessing different organ procurement organization (OPO) regions with varying donor availability and wait times 1. However, allocation systems prioritize organs based on geographic proximity, with broader sharing occurring primarily for the highest-acuity patients 2.

Key considerations for your specific scenario:

• Geographic overlap: Centers 4 hours apart typically fall within the same regional allocation zone or have substantial donor pool overlap, particularly for urgent status patients who access broader geographic areas 2
• Allocation hierarchy: High-priority patients (MELD ≥30, Status 1A cardiac) already access nationwide or macro-area allocation, making secondary listing at nearby centers redundant 2

Evidence on Multiple Listing Outcomes

Heart Transplantation Data

Multiple listing in heart transplantation demonstrates that it primarily advantages patients with resources rather than medical need 1:

• Only 2.0% of candidates utilize multiple listing 1
• Multiple-listed patients are younger, wealthier (median income $90,153 vs $68,986), more often white, and privately insured 1
• These patients had lower initial medical urgency (39.0% high priority vs 55.1%) but were frequently upgraded at secondary centers (58.2%), suggesting gaming of the system 1
• Multiple listing increased transplant rates (74.4% vs 70.2%) but did not improve post-transplant survival 1

Lung Transplantation Data

Similar patterns emerge in lung transplantation 3:

• Multiple listing occurred in only 2.3% of candidates 3
• Associated with increased likelihood of transplant (aHR 2.74) but no reduction in waitlist mortality (aHR 0.99) 3
• Predominantly utilized by younger, white, female, highly educated patients with lower lung allocation scores 3

Ethical and Practical Concerns

The practice raises significant equity issues 1:

• Multiple listing advantages patients with financial resources and mobility rather than those with greatest medical need 1
• It may allow less sick patients to receive organs ahead of sicker patients at single centers 1
• The policy has been called into question, with recommendations that it "should be overturned" 1

Regional Allocation Principles

Modern allocation frameworks emphasize that regional procedures offer advantages for non-urgent cases 2:

• Easier donor-recipient matching within regions 2
• Greater flexibility in allocation decisions 2
• Benefit and utility endpoints are better managed regionally rather than through multiple distant listings 2

Clinical Recommendation Algorithm

For centers 4 hours apart, do NOT pursue multiple listing if:

1. The patient has high medical urgency (MELD ≥30, Status 1A/1B cardiac, high lung allocation score) - these patients already access broad geographic areas 2
2. Both centers fall within the same OPO or adjacent OPOs with similar wait times
3. The primary motivation is to "game the system" rather than access genuinely different donor pools 1

Consider multiple listing ONLY if:

1. Centers are in demonstrably different allocation zones with documented substantial wait time differences
2. Patient has stable disease allowing safe waiting at lower priority 2
3. Patient has financial resources and mobility to maintain active status at both centers without compromising care 1, 3
4. The decision is transparent and discussed with both transplant teams 4

Common Pitfalls to Avoid

• Assuming geographic distance equals different donor pools: Four hours may still be within overlapping allocation zones 2
• Upgrading priority at secondary centers: This practice undermines allocation equity and has been documented as problematic 1
• Ignoring resource requirements: Multiple listing requires significant financial resources, frequent travel, and duplicate evaluations 1, 3
• Failing to communicate between centers: Noncompliance or substance abuse issues should be shared to prevent inappropriate allocation 4

Bottom Line

Given the 4-hour proximity, the centers likely share substantial donor pool overlap, making multiple listing an inefficient use of resources that primarily advantages those with means rather than medical need 1. Focus instead on optimizing care at a single high-quality center, ensuring appropriate priority status, and maintaining transplant readiness 2.