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Importance: A new liver allocation policy was implemented by United Network for Organ Sharing (UNOS) in February 2020 with the stated intent of improving access to liver transplant (LT). There are growing concerns nationally regarding the implications this new system may have on LT costs, as well as access to a chance for LT, which have not been captured at a multicenter level. Objective: To characterize LT volume and cost changes across the US and within specific center groups and demographics after the policy implementation. Design, Setting, and Participants: This cross-sectional study collected and reviewed LT volume from multiple centers across the US and cost data with attention to 8 specific center demographics. Two separate 12-month eras were compared, before and after the new UNOS allocation policy: March 4, 2019, to March 4, 2020, and March 5, 2020, to March 5, 2021. Data analysis was performed from May to December 2022. Main Outcomes and Measures: Center volume, changes in cost. Results: A total of 22 of 68 centers responded comparing 1948 LTs before the policy change and 1837 LTs postpolicy, resulting in a 6% volume decrease. Transplants using local donations after brain death decreased 54% (P < .001) while imported donations after brain death increased 133% (P = .003). Imported fly-outs and dry runs increased 163% (median, 19; range, 1-75, vs 50, range, 2-91; P = .009) and 33% (median, 3; range, 0-16, vs 7, range, 0-24; P = .02). Overall hospital costs increased 10.9% to a total of $46â¯360â¯176 (P = .94) for participating centers. There was a 77% fly-out cost increase postpolicy ($10â¯600â¯234; P = .03). On subanalysis, centers with decreased LT volume postpolicy observed higher overall hospital costs ($41â¯720â¯365; P = .048), and specifically, a 122% cost increase for liver imports ($6â¯508â¯480; P = .002). Transplant centers from low-income states showed a significant increase in hospital (12%) and import (94%) costs. Centers serving populations with larger proportions of racial and ethnic minority candidates and specifically Black candidates significantly increased costs by more than 90% for imported livers, fly-outs, and dry runs despite lower LT volume. Similarly, costs increased significantly (>100%) for fly-outs and dry runs in centers from worse-performing health systems. Conclusions and Relevance: Based on this large multicenter effort and contrary to current assumptions, the new liver distribution system appears to place a disproportionate burden on populations of the current LT community who already experience disparities in health care. The continuous allocation policies being promoted by UNOS could make the situation even worse.
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BACKGROUND: There is a discrepancy between the reported increase in donor conversion rates and the number of organs available for transplant. METHODS: Secondary analysis of data obtained from the Scientific Registry of Transplant Recipients from January 2003 through December 2015 was performed. The primary outcomes were the (1) number of brain-dead donors from whom solid organs were recovered and (2) number of the organs transplanted. Descriptive statistics and growth plots were used to examine the trajectory of organ donation, recovery, and transplantation outcomes over the 11-year period. RESULTS: From 2003 to 2006, the number of brain-dead donors increased from 6187 to 7375, remaining relatively stable at approximately 7200 thereafter. The average eligible deaths per organ procurement organization dropped from 182.7 (standard deviation [SD]: 131.3) in 2003 to 149.3 (SD: 111.4) in 2015. This suggests a total of 12 493 unrealized potential donors (2006-2015). CONCLUSIONS: Since 2006, a steady decline in the number of donor-eligible deaths was reported. In 2003, the reported eligible deaths was 11 326. This number peaked in 2004 at 11 346, tumbling to 9781 eligible donors in 2015, despite a 9% increase in the US population. From 2006 to 2015, the data indicate an artificial depression and underestimation of the true potential of brain-dead donors in the United States of conservatively 12 493 donors or 39 728 missing organs. New metrics providing objective but verifiable counts of the donor pool are needed.
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Trasplante de Órganos/estadística & datos numéricos , Trasplante de Órganos/tendencias , Donantes de Tejidos/provisión & distribución , Donantes de Tejidos/estadística & datos numéricos , Obtención de Tejidos y Órganos/estadística & datos numéricos , Obtención de Tejidos y Órganos/tendencias , Predicción , Humanos , Sistema de Registros , Estados UnidosRESUMEN
Patients' deaths due to the organ donor shortage make it imperative that every suitable organ be transplanted. False-positive results of tests for infection with the human immunodeficiency virus (HIV) result in lost organs. A survey of US organ procurement organizations collected the numbers of donors and ruled-out potential donors who had a positive result on an HIV test from January 1,2006, to October 31, 2008. Sixty-two percent of US organ procurement organizations participated. Of the 12397 donor/nondonor cases, 56 (0.45%) had an initial positive result on an HIV antibody or HIV nucleic acid test, and only 8 (14.3%) of those were confirmed positive. Of the false-positive results, 50% were from HIV antibody tests and 50% were from HIV nucleic acid tests. Organs are a scarce, finite, and perishable resource. Use of HIV antibody testing has produced a remarkably safe track record of avoiding HIV transmission, with 22 years of nonoccurrence between transmissions. Because false positives occur with any test, including the HIV Ab test, adding nucleic acid testing to the standard donor testing panel doubles the number of false-positive HIV test results and thus the number of medically suitable donors lost. The required HIV antibody test is 99.99% effective in preventing transmission of the HIV virus. Adding the HIV nucleic acid test to routine organ donor screening could result in as many as 761 to 1551 unnecessary deaths of patients between HIV transmission events because medically suitable organs are wasted.
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Infecciones por VIH/prevención & control , Política de Salud , Técnicas de Amplificación de Ácido Nucleico , Donantes de Tejidos/provisión & distribución , Obtención de Tejidos y Órganos , Serodiagnóstico del SIDA , Análisis Costo-Beneficio , Reacciones Falso Positivas , Infecciones por VIH/transmisión , Humanos , Medición de Riesgo , Estados UnidosRESUMEN
More than 92000 Americans are on waiting lists for organ transplants, and an average of 17 of them die each day while waiting. The US Organ Donation Breakthrough Collaborative (ODBC), which began in 2003 at the request of the Secretary of the US Department of Health and Human Services, was a formal, concerted effort of the donation and transplantation community to bring about a major change to improve the organ donation system. The nationwide Collaborative was housed within a Health and Human Services agency, the Health Resources and Services Administration (HRSA) Division of Transplantation, and included participation of the organ procurement organizations (OPOs) throughout the United States and the American hospitals with the largest organ-donor potential. HRSA leaders used the Breakthrough Series Collaborative method, originally developed by the Institute for Healthcare Improvement, as the model for the intervention. Expert practitioners drawn from hospitals and OPOs that had already demonstrated their ability to achieve and sustain high organ donation rates were chosen as faculty for the collaborative and best practices were gleaned from their institutions. The number of organ donors in Collaborative hospitals increased 14.1% in the first year, a 70% greater increase than the 8.3% increase experienced by non-Collaborative hospitals. Moreover, the increased organ recovery continued into the post-Collaborative periods. Between October 2003 and September 2006, the number of total US organ donors increased 22.5%, an increase 4-fold greater than the 5.5% increase measured over the same number of years in the immediate pre-Collaborative period. The study did not involve a randomized design, but time-series analysis using statistical process control charts shows a highly significant discontinuity in the rate of increase in participating hospitals concurrent with the Collaborative program, and strongly suggests that the activities of the Collaborative were a major contributor to this increase. Given the stable nature of the historical increases over many years, the HRSA estimates that more than 4000 annual additional transplants have occurred in association and apparently as a result of these increases in organ donation.
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Conducta Cooperativa , Administración Hospitalaria , Relaciones Interinstitucionales , Donantes de Tejidos/provisión & distribución , Obtención de Tejidos y Órganos/organización & administración , United States Health Resources and Services Administration/organización & administración , Benchmarking , Análisis Costo-Beneficio , Necesidades y Demandas de Servicios de Salud , Investigación sobre Servicios de Salud , Administración Hospitalaria/métodos , Administración Hospitalaria/estadística & datos numéricos , Humanos , Liderazgo , Estudios Longitudinales , Modelos Organizacionales , Objetivos Organizacionales , Evaluación de Procesos y Resultados en Atención de Salud , Evaluación de Programas y Proyectos de Salud , Análisis de Regresión , Gestión de la Calidad Total/organización & administración , Estados Unidos , Listas de EsperaAsunto(s)
Conducta Cooperativa , Relaciones Interinstitucionales , Guías de Práctica Clínica como Asunto , Donantes de Tejidos/estadística & datos numéricos , Obtención de Tejidos y Órganos/organización & administración , Femenino , Humanos , Relaciones Interprofesionales , Masculino , Evaluación de Necesidades , Rol de la Enfermera , Desarrollo de Programa , Evaluación de Programas y Proyectos de Salud , Factores de Riesgo , Gestión de la Calidad Total , Estados Unidos , Listas de EsperaRESUMEN
PURPOSE: Daily presence of organ procurement organization staff in level I trauma centers combined with early family contact and interaction can increase donation rates. METHODS: A successful in-house coordinator program already in place at 2 level I trauma centers in Houston was replicated in 6 other level I trauma centers in New York City, Los Angeles, and Seattle. Organ procurement organization staff were placed inside the 8 trauma centers to provide early family support in potential donor situations and day-to-day donation system management. Comparison data were obtained on 83 level I trauma centers nationally. Data from 1999 to 2000 were compared with data from 2001 to 2002. RESULTS: Despite demographic differences, the 8 centers with in-house coordinators had higher consent rates (60% vs 53%) and conversion rates (55% vs 45%) than centers without them. Conversion of potential to actual donors was 22% higher in centers with in-house coordinators than in centers without them. Donation rates were affected by donor age, ethnicity, previous family discussion of donation, the family's initial reaction to the request (favorable, unfavorable, undecided), amount of time family spent with the in-house coordinator, presence of the in-house coordinator during explanation of brain death, whether the request was made at the same time as the brain-death explanation, and, in cases where donation was mentioned to the family before the formal request, who first mentioned donation to the family. CONCLUSIONS: In-house coordinators improve the donation process by interacting with families and staff earlier and more often during potential organ donations and improving donation systems through closer relationships with hospital staff.
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Manejo de Caso/organización & administración , Continuidad de la Atención al Paciente/organización & administración , Obtención de Tejidos y Órganos/organización & administración , Gestión de la Calidad Total/organización & administración , Centros Traumatológicos/organización & administración , Familia/psicología , Femenino , Investigación sobre Servicios de Salud , Humanos , Consentimiento Informado/psicología , Consentimiento Informado/estadística & datos numéricos , Los Angeles , Masculino , Modelos Organizacionales , Ciudad de Nueva York , Rol Profesional , Evaluación de Programas y Proyectos de Salud , Derivación y Consulta/organización & administración , Apoyo Social , Texas , Factores de Tiempo , WashingtónRESUMEN
Many people die owing to the shortage of donor organs. Medical examiners and coroners (MEs/Cs) play a vital role in making organs available for potential recipients. Medical examiners'/coroners' case data were collected using a structured confirmatory-recorded methodology for calendar years 2000-01 and were linked and analyzed with donor and transplant data from the United Network for Organ Sharing, predicting the nature and extent of the loss of donor organs. Nearly seven percent of ME/C cases were denied recovery during 2000-01. Because 353 and likely, 411 potential organ donors (PODs) were denied, as many as 1400 persons on transplant waiting lists did not receive organs because of ME/C denials. Problematically for pediatric patients awaiting transplantation, nearly half of all ME/C denials occurred in pediatric patients. Eighteen percent of PODs aged five or less and 44.2% of child abuse PODs were denied recovery by the ME/C. There were no (zero) denials in three of the five largest U.S. cities and in four states. Since 1994, two states have enacted legislation restricting the circumstances of ME/C denials, resulting in an 83% decrease in ME/C denials. Release of all organs from ME/C cases is needed urgently to protect the lives of those persons awaiting transplantation. Medical examiners and coroners deserve recognition for their efforts in advocating methods and/or regulation/legislation designed to achieve 100% release of life-saving organs for transplantation.
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Médicos Forenses , Donantes de Tejidos/provisión & distribución , Cadáver , Humanos , Selección de Paciente , Obtención de Tejidos y Órganos/organización & administración , Estados UnidosRESUMEN
BACKGROUND: Of 5810 acute care hospitals in the United States, only 3.9% (231) are Level 1 Trauma Centers (L1TCs). L1TCs have a significant number of potential organ donors (PODs). Placement of Organ Procurement Organization (OPO) staff, In House Coordinators (IHCs), directly within the L1TC to increase the number of families who consent to donate and to provide system management for the trauma center's donation program, was evaluated. METHODS: Four OPO staff, IHCs, were placed in offices inside two L1TCs in Houston, Texas. The IHCs were responsible for development of a donation system, donor surveillance, management, and most importantly, family support. RESULTS: Calendar year 2000 data on conversion of PODs to actual donors were compared between the L1TCs with IHCs (IHC-L1TC) (n=2) and trauma centers without IHCs (n=4) within the OPO's service area. IHC-L1TCs converted 44% more of the PODs to actual donors. Furthermore, the IHC-L1TCs were compared with 85 L1TCs (37% of U.S. L1TCs) without IHCs. IHC-L1TCs had a 28% greater donor consent rate and a 48% greater conversion rate of PODs to actual donors than the national L1TCs. CONCLUSIONS: L1TC status is the America College of Surgeons' highest level of verification for trauma care. To be certified as a L1TC, hospitals must meet strict criteria in both services and patient care. The donation process is often profoundly affected by the burden of demands made on the resources of these institutions and from divergent responsibilities between specialty services within the facility. Dedicated IHCs (OPO staff) are needed to provide early family intervention and to orchestrate the donation process to maximize organ recovery.
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Administradores de Hospital , Donantes de Tejidos/provisión & distribución , Obtención de Tejidos y Órganos/organización & administración , Centros Traumatológicos/organización & administración , Certificación , Humanos , Selección de Personal , Relaciones Profesional-Familia , Texas , Consentimiento por Terceros , Centros Traumatológicos/normasRESUMEN
This study builds on previous research that identified fears and concerns heard by procurement coordinators during the donation discussion and that classified those concerns according to the ease with which they can be addressed. In this study, 53 coordinators working for 4 procurement agencies provided data on 323 donation discussions, including fears and concerns expressed by families. The fears and concerns were analyzed by outcome (consent or refusal), race and ethnicity of the family, frequency of reports, and difficulty in addressing. This research confirms many of the findings of the earlier study. The results also indicate that the types of concerns expressed by donor and non-donor families vary somewhat by the family's race and ethnicity. The results can be used to provide training targeted at raising consent rates and to train minority requestors.