Unintended consequences of changes to lung allocation policy

Puri, Varun; Hachem, Ramsey R.; Frye, Christian; Harrison, M. Shea; Semenkovich, Tara R.; Lynch, John P.; Ridolfi, Gene; Rowe, Casey; Meyers, Bryan F.; Patterson, G. A.; Kozower, Benjamin D.; Pasque, Michael K.; Nava, Ruben G.; Marklin, Gary; Brockmeier, Diane; Sweet, Stuart C.; Chapman, William C.; Kreisel, Daniel

doi:10.1111/ajt.15307

Cited by 50 publications

(53 citation statements)

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“…The rationale for prioritizing patients based on proximity re ects both system e ciency and organ viability considerations, as transporting lungs over long distances incurs transportation costs, travel time by the surgical recovery team, and potentially detrimental effects of organ ischemia time [15][16][17][18][19]. The manner and degree to which proximity should in uence candidate rankings is a matter of ongoing debate [20][21][22].…”

Section: Discussionmentioning

confidence: 99%

A Revealed Preference Analysis to Develop Composite Scores Approximating Lung Allocation Policy in the U.S.

Stewart¹,

Wood

Alcorn³

et al. 2020

Preprint

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Background: The patient ranking process for donor lung allocation in the United States is carried out by a classification-based, computerized algorithm, known as the match system. Experts have wondered whether a continuous, points-based allocation framework would better serve waiting list candidates by removing hard boundaries and increasing transparency into the relative importance of factors used to order candidates. We applied discrete choice modeling to match run data to determine the feasibility of approximating current lung allocation policy by one or more composite scores. Our study aimed to demystify the points-based approach to allocation; quantify the relative importance of factors used in allocation under current policy; and provide a viable policy option that adapts the current, classification-based system to the continuous allocation framework.Methods: Rank ordered logistic regression models were estimated using 6,466 match runs for 5,913 adult donors and 534 match runs for 488 pediatric donors from 2018. Four primary attributes are used to rank candidates and were included in the models: (1) medical priority, (2) candidate age, (3) candidate’s transplant center proximity to the donor hospital, and (4) blood type compatibility with the donor.Results: Two composite scores were developed, one for adult and one for pediatric donor allocation. Candidate rankings based on the composite scores were highly correlated with current policy rankings (Kendall’s Tau ~0.80, Spearman correlation >90%), indicating both scores strongly reflect current policy. In both models, candidates are ranked higher if they have higher medical priority, are registered at a transplant center closer to the donor hospital, or have an identical blood type to the donor. Proximity was the most important attribute. Under a points-based scoring system, candidates in further away zones are sometimes ranked higher than more proximal candidates compared to current policy. Conclusions: Revealed preference analysis of match runs produced composite scores that capture the essence of current policy while removing hard boundaries of the current classification-based system. A carefully crafted, continuous version of lung allocation policy has the potential to make better use of the limited supply of donor lungs in a manner consistent with the priorities of the transplant community.

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Section: Discussionmentioning

confidence: 99%

A Revealed Preference Analysis to Develop Composite Scores Approximating Lung Allocation Policy in the U.S.

Stewart¹,

Wood

Alcorn³

et al. 2020

Preprint

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“…An emergency change to lung allocation policy was instituted after a court challenge in 2017, changing allocation from one based on donor service areas to one that would offer organs within a 200-nautical-mile radius of the transplant center (crossing over donor service areas). An analysis by Puri et al 13 revealed that after this change, there was no difference in 30-, 60-, or 90-day mortality of patients at their center (so no overall improvement in utility), but the organ retrieval costs increased significantly, from $34 000 to $70 000 per organ. Additionally, there was a significant increase in the mean ischemic time, from 204 to 244 minutes, meaning that the organs spent more time "on ice" instead of in the body of the recipient, which could adversely affect long-term survival.…”

Section: Sarah Murnaghan: Challenging the Evidence On Allocationmentioning

confidence: 99%

“…Additionally, there was a significant increase in the mean ischemic time, from 204 to 244 minutes, meaning that the organs spent more time "on ice" instead of in the body of the recipient, which could adversely affect long-term survival. 13 The authors of this study stated as follows:…”

Section: Sarah Murnaghan: Challenging the Evidence On Allocationmentioning

confidence: 99%

“…How they balance out should be for the transplant community and not the courts to decide since legal experts stipulating these changes are unlikely to understand the complex environment and the myriad of down-stream effects. 13 If the Murnaghan case is viewed only as the story of a single child and her family's ability to fight for her from a relatively privileged position, it could be seen as a work-around to the well-intended efforts of the OPTN to make difficult allocation decisions. But when viewed as the story of a single child who brought to light weaknesses in the evidence for one particular rule, it speaks to the power of narrative and how it sometimes takes a single story to effect a change that is fair and necessary.…”

Section: Sarah Murnaghan: Challenging the Evidence On Allocationmentioning

confidence: 99%

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Public Appeals Challenging Criteria for Pediatric Organ Transplantation

Goldberg

2020

Pediatrics

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In this article, I review the ethical issues that arise in the allocation of deceased-donor organs to children and young adults. By analyzing the public media cases of Sarah Murnaghan, Amelia Rivera, and Riley Hancey, I assess whether public appeals to challenge inclusion and exclusion criteria for organ transplantation are ethical and under which circumstances. The issues of pediatric allocation with limited evidence and candidacy affected by factors such as intellectual disability and marijuana use are specifically discussed. Finally, I suggest that ethical public advocacy can coexist with well-evidenced transplant allocation if and when certain conditions (morally defensible criteria, expert evidence, nonprioritization of the poster child, and greater advocacy for organ transplantation in general) are met.

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“…New organ allocation policies that mandate broader sharing highlight the need to urgently address transportation safety. Implementation of the new thoracic organ allocation system has already led to a 45% increase in the median distance for lung recovery 7,8 . The recently implemented liver reallocation policy is predicted reduce local allocation from 76% to approximately 10%, increased air travel from 50% to 71% of recoveries 9,10 .…”

Section: Introductionmentioning

confidence: 99%

Improving safety in organ recovery transportation: Report from the ASTS/UNOS/AST/AOPO transportation safety summit

Axelrod

Shah

Guarrera

et al. 2020

American Journal of Transplantation

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Solid organ transplantation is an inherently complex enterprise requiring robust systems of quality assurance and process controls to ensure that procedures are safely performed. The community has demonstrated the ability to act decisively to improve care processes, especially following sentinel events. In response to the accidental transplantation of an ABO incompatible heart-lung allograft at Duke in 2003, the United Network for Organ Sharing developed procedures to ensure that compatibility is assured prior to organ recovery and transplantation. 1 Similarly, following the transmission of human immunodeficiency virus (HIV) to 4 patients in Chicago in 2007, a system of universal nucleic acid testing was implemented for deceased donors. 2 In each case, the transplant community enacted national standards and practices to protect safety without regard to cost or efficiency. Unfortunately, the same diligence has not been practiced to ensure the safety of members of transplantation teams and organ procurement organization (OPO) personnel who must travel to other centers to recover lifesaving organs. In 2007, the tragic loss of a University of Michigan team in a plane crash over Lake Michigan should have been a sentinel event, warranting the same thoughtful and universal standards as the events noted

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Unintended consequences of changes to lung allocation policy

Cited by 50 publications

References 9 publications

A Revealed Preference Analysis to Develop Composite Scores Approximating Lung Allocation Policy in the U.S.

A Revealed Preference Analysis to Develop Composite Scores Approximating Lung Allocation Policy in the U.S.

Public Appeals Challenging Criteria for Pediatric Organ Transplantation

Improving safety in organ recovery transportation: Report from the ASTS/UNOS/AST/AOPO transportation safety summit

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