Same quality – higher price? The paradox of allocation: the first national single center analysis after the implementation of the new Swiss transplantation law: the ICU view Since liver transplantation has become a univer- sally accepted treatment for end-stage liver disease (ESLD), the number of patients accumulating on the waiting list has gradually outweighed the scarce resources of available organs. Fair allocation of donor livers to patients with ESLD is a difficult task. The United States and Europe used prioriti- zation systems based on waiting time and on the parameters of the Child-Turcotte-Pugh score (1). Unfortunately, this system could not evaluate urgency of transplantation. Since February 2002, the United Network for Organ Sharing (UNOS) introduced a new allocation policy for cadaveric liver transplants, based on the Model for End- Stage Liver Disease (MELD) score (2). This new policy stratifies the patients on the basis of their risk of death while on the waiting list (3). It is also used in several other countries (Germany, Benelux, Austria, Slovenia, etc.) In Switzerland, the allocation of organs to patients with ESLD was, until June 30, 2007, a center-oriented allocation system in which each transplant center allocated by its own allocation criteria. This allocation system is still present in many other countries (Spain, Sweden, Finland, Norway, etc.). Since July 1, 2007, national allocation of donor organs for transplantation is regulated by the amendment of the Swiss transplant act, and Switzerland took the already established MELD Oberkofler CE, Stocker R, Raptis DA, Stover JF, Schuepbach RA, Mu¨llhaupt B, Dutkowski P, Clavien P-A, Be´chir M. Same quality – higher price? The paradox of allocation: the first national single center analysis after the implementation of the new Swiss transplantation law: the ICU view. Clin Transplant 2011: 25: 921–928. ª 2010 John Wiley & Sons A/S. Abstract: This study was undertaken as the first national single-center analysis to assess the impact of the new Swiss transplantation law on patient selection, intensive care unit (ICU) complications, outcome, and, in par- ticular, costs in liver transplant recipients treated in our surgical ICU. The first 35 consecutive liver transplant recipients following the new act were compared with the last 35 liver transplant recipients preceding July 1, 2007. Following execution of the new law, recipients were in poorer condition, reflected by significant higher Model for End-Stage Liver Disease (MELD) scores (12 vs. 22; p = 0.006). Furthermore, the MELD group obtained more renal replacement therapies (40.0% vs. 14.3%; p = 0.015). Cumula- tive one-yr patient survival was comparable in both groups (91.4% vs. 80.1%, p = 0.22). Finally, the additional costs per single case increased 27 000 Euros after the adoption of the new law. Our data serve as an example that political decisions influence patientÕs selection, and, in turn, complications, finally leading to higher costs of medical treatment. Liver graft allocation according to the MELD system may save lives at the price of increased intensive care efforts. Christian E. Oberkofler a,b *, Reto Stocker a *, Dimitri A. Raptis b , John F. Stover a , Reto A. Schuepbach a , Beat Mu ¨ llhaupt c , Philipp Dutkowski b , Pierre-Alain Clavien b and Markus Be ´ chir a a Surgical Intensive Care Medicine, b Department of Visceral- and Transplantation Surgery, c Department of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich, Switzerland Key words: cost analysis – ICU mortality – liver transplantation – MELD score – renal failure – renal replacement therapy Corresponding author: Dr. med. Markus Be ´ chir, Surgical Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland. Tel.: +41 44 255 41 94; fax: +41 44 255 31 72; e-mail: markus.bechir@usz.ch Conflict of interest: None. *These authors contributed equally to this work. Accepted for publication 4 October 2010 Clin Transplant 2011: 25: 921–928 DOI: 10.1111/j.1399-0012.2010.01364.x ª 2010 John Wiley & Sons A/S. 921