In the United Kingdom, the number of patients waiting to receive a kidney transplant far outstrips the supply of donor organs, thereby making some form of rationing inevitable. The criteria for rationing can be made explicit in the design of a kidney allocation scheme, which typically aims to achieve a balance between efficiency, defined as maximising health benefits from a limited resource, and equity in the distribution of that resource. In the past, kidney allocation schemes have focussed on waiting time as one of the criteria to promote equity in access to transplantation. Over time, increasing emphasis has been placed on closer tissue matching between recipients and donors after this was shown to result in better post-transplant outcomes. More recently, there has been recognition of variability in the quality of donor kidneys such that not all donor kidneys will result in equally good survival outcomes and not all patients will derive the same benefit from a given donor kidney. This thesis describes the development of a patient-level simulation model that compares five different approaches to allocating kidneys from across the equity-efficiency spectrum. Emphasis is placed on characterising heterogeneity in the data inputs that are used to inform the simulation. This is achieved by using various regression modelling strategies to analyse patient-level data to facilitate prediction of costs, health-state utilities and survival conditional on covariates such as age, comorbidities and treatment modality. For each allocation scheme, the simulation model reports total costs, life years and quality-adjusted life years across the patient population. The simulation model can be used to quantify not only the magnitude of health gains associated with moving from one kidney allocation approach to another, but also the impact in terms of equity in access to transplantation and the distribution of outcomes across different patient groups. The outputs of the simulation can be used to inform discussions about equity-efficiency tradeoffs in the design of a kidney allocation policy
