Assessing the outcome of organ allocation: choosing metrics

Abstract

Purpose of reviewOrgan allocation is a highly complex process with significant impact on outcomes of donor organs and end-stage organ disease patients. Policies governing allocation must incorporate numerous factors to meet stated objective. There have been significant alterations and ongoing discussion about changes in allocation policy for all solid organs in the United States. As with any policy change, rigorous evaluation of the impact of changes is important. Recent findingsThis manuscript discusses metrics to consider to evaluate the impact of organ allocation policy that may be monitored on an ongoing basis including examples of research evaluating current policies. Potential metrics to evaluate allocation policy include the effectiveness, efficiency, equity, costs, donor rates, and transparency associated with the system. SummaryUltimately, policies will often need to adapt to secular changes in donor and patient characteristics, clinical and technological advances, and overarching healthcare polices. Providing objective empirical evaluation of the impact of policies is a critical component for assessing quality of the allocation system and informing the effect of changes. The foundation of organ transplantation is built upon public trust and the dependence on the gift of donor organs, as such the importance of the most appropriate organ allocation policies cannot be overstated.

The Effect of Priority Given to Donor Card Holders on the Allocation of Livers for Transplant—Evidence From 7 Years of the Israeli Priority Program

“…However, this will be reassuring for those concerned that candidates with supportive families may be unfairly advantaged, especially given that, of the 223 transplant candidates who held priority of some kind, 64% did so because of their relatives' actions rather than their own. 7 These results seem generally positive for proponents of such priority programs; if there were no benefits, then the incentive to register as a donor in the hope of obtaining a transplant would presumably disappear once people become aware of this fact. The priority program appears to succeed in rewarding registered donors by conferring an advantage in accessing a liver transplant; however, it appears to be ineffective in encouraging donor registration and hence deterring "free riders."…”

“…Nevertheless, it is vital that the outcomes of policies are carefully evaluated to determine if goals are achieved or ethically unacceptable costs incurred. 7 Analysis by Ashkenazi et al 8 of the impact of the program on allocation of livers and thus on waiting list mortality and transplantation rates for liver transplant candidates is therefore particularly valuable. Although it does not provide conclusive answers to all the ethical questions raised by the program, it sheds light on several concerns and reveals the need for further empirical evaluation to inform ethical policy and practice.…”

“…However, this will be reassuring for those concerned that candidates with supportive families may be unfairly advantaged, especially given that, of the 223 transplant candidates who held priority of some kind, 64% did so because of their relatives’ actions rather than their own. 7…”