Evolving ethics, policy and reimbursement issues of vascularized composite allotransplantation: Symposium summary

Abstract

In this article, we present a report from a national meeting titled, “Evolving Issues of Vascularized Composite Allotransplantation—A Symposium on Ethics, Policy, and Reimbursement Issues,” which convened in September 2017. We discuss the maturation of vascularized composite allotransplantation from an emerging technology to becoming an extension of clinical practice for select patients with complex reconstructive needs. Viewpoints and action items were presented by and discussed among the 70+ clinicians, researchers, policymakers, ethicists, healthcare administrators, and third-party payers who attended the symposium with the goals of implementing a collaborative roadmap for vascularized composite allotransplantation growth, evaluation, and sustainability by establishing a unified plan to help address concerns of the public, policymakers, and healthcare finance. We review the current status of vascularized composite allotransplantation in clinical practice and summarize symposium discussions regarding ethical considerations, reimbursement, payer strategies, and standardization of data collection.

What is needed to ensure long-term sustainability for the field of vascularized composite allotransplantation?

“…In the US, the Organ Procurement and Transplantation Network (OPTN) oversees organ donation and transplantation under the United Network for Organ Sharing (UNOS). Since 2014, the OPTN Final Rule added VCAs to the definition of 'organs' under its governance [32,47,48].…”

“…It is also difficult to perform a cost analysis due to the variable procedures and frequent lack of appropriate alternatives for comparison. A time trade-off survey study calculated quality-adjusted life years to compare costs of upper extremity VCA, including perioperative care and lifelong immunosuppression, to that of prostheses, including initial costs and maintenance requirements, and found that bilateral, but not unilateral, hand transplantation was costeffective [14,47,53]. Limitations to this analysis include inability to financially quantify the improvement in quality of living with a transplanted arm compared to a prosthesis, which do not return sensation, fine motor control, or tactile aesthetics of human tissue as VCA can [29].…”

“…The DoD has indicated interest with substantial funding for the recipients and VCA centers [50]. Currently, many US VCA centers rely on DoD grants, institutional support, and philanthropy as third-party payers do not reliably fund VCA care [47,50]. Lack of insurance coverage and disparity in evaluation criteria for VCA may lead to access inequity [9 ▪▪ ].…”

Information needs and development of a question prompt sheet for upper extremity vascularized composite allotransplantation: A mixed methods study

“…Upper extremity VCA is one of several treatment options (e.g., myoelectric and mechanical prostheses) for people with UE amputations. UE VCA is an innovative treatment modality that restores body wholeness and function for patients with complex reconstructive needs ( Rose et al, 2019 ). Evidence suggests that people with UE amputations lack awareness and knowledge of UE VCA.…”

Vascularized composite allotransplantation: emerging psychosocial issues in hand, face, and uterine transplant

“…In addition to the functional outcomes achieved by these evolving surgical techniques, recent research approaches have shown that psychosocial and bioethical issues significantly influence the outcomes [1 ▪▪ ]. VCA, particularly in the case of UETx and FTx but also in UTx (by providing the ability to give birth), restores body wholeness and function for patients with complex reconstructive needs [2]. In the introductory phase of a novel type of transplantation, with unknown medical and psychological risks, it is of great importance to follow the patients concerning all aspects of their health.…”