PERSPECTIVE Transplantation Traffic — Geography as Destiny for Transplant Candidates Peter A. Ubel , M.D. N Engl J Med 371:2450 - 2452 | December 25 , 2014 Steve Jobs had a problem. He needed a liver transplant, but people in northern California, where he lived, waited more than 6 years on average before an organ became available. So he got himself listed at a second transplant center, one in Memphis, Tennessee, where average wait times were less than 3 months.1 When an organ became available at that distant location, Jobs chartered a private jet and went to receive the transplant. Since the 1990s, experts have documented dramatic geographic disparities in access to life-saving transplantable organs.2 These disparities exist because the transplant-allocation system gives priority to local patients, and the supply of transplantable organs does not vary in proportion to the population of patients needing transplants. And despite a call from the Department of Health and Human Services, in 2000, for the transplant community to revise the organ-allocation system so “neither place of residence nor place of listing shall be a major determinant of access to a transplant,”3 the disparities persist. The transplant community is considering rule revisions that would reduce these disparities by ensuring that organs are shared more widely throughout the country. But these revisions are mired in political deadlock. Given the intransigence of the transplant community to date, some relatively wealthy patients have taken it upon themselves to become listed where organs are more abundant, and some companies have been created to enable a wider range of patients to follow suit. Such developments raise important questions about whats keeping the transplant community from fixing the system and whether the best way to make it fairer is to fly organs to patients or to fly patients to organs. Under the current system, the United States is divided into 58 donation service areas (DSAs) in 11 regions. When a transplantable cadaveric liver, for example, becomes available, its offered to patients in the same DSA, with the sickest patients receiving priority. If theres no suitable recipient in the DSA, the liver is offered within the wider region, and if no suitable candidate can be found there, its made available nationally. Geographic disparities in transplant access could be reduced by requiring transplant centers to share organs more broadly or by redefining regional boundaries to smooth out gaps between supply and demand (as in the proposal under consideration by the United Network for Organ Sharing [see article by Lamas and Rosenbaum, pages 2447–2450]). There are important medical barriers to broader sharing of transplantable organs, chief among them being the damage caused to organs during ischemic time. Nevertheless, medical factors are not the greatest barrier to broader sharing. Preservation techniques allow for organs to be shared across substantial distances with minimal effects on organ function, and many adjoining DSAs and regions are close enough together that broader sharing of organs would not substantially increase ischemic damage. The larger barrier appears to be political: broader organ sharing is opposed by some smaller transplant programs, in part because they want to be able to offer a full range of services to patients in their care and in part because they would stand to lose business under such a system.4 With increased organ sharing across regions, many transplant programs would become net exporters of organs. Some small transplant programs might well go out of business, because when scarce organs became available, larger programs with longer lists of sicker patients would often receive organs ahead of them. Broader organ sharing might not only doom these smaller programs but could also potentially threaten the viability of their parent health care institutions, if they depend on transplantations to support their overall business. An alternative to mobilizing the transplants is mobilizing the recipients — but of course, most people cant afford to do what Steve Jobs did. Less than 6% of transplant candidates are listed at multiple transplant centers, and less than 2% get listed at transplant centers a long distance from where they live.5 Private enterprise may broaden the population of patients who can afford to receive transplants from distant centers. For example, a start-up company called OrganJet hopes to make long-distance listing more affordable and feasible by charging patients or insurance companies a fee of approximately $8,000 per flying hour if patients take an on-demand flight made available by the company. The company has developed an algorithm for identifying underutilized private jets. Having a flight at ready disposal is critical because many transplant programs require patients to arrive within 6 hours after an organ is procured, or they move on to the next person on the list. Theres reason to think that transporting patients to distant centers would not face the same kind of political resistance that has stood in the way of broader organ sharing to date. If patients, rather than organs, did the traveling, smaller transplant programs would not lose business, because the number of transplantations they performed would still largely be determined by the number of organs procured in their DSA or region. Nevertheless, the practice of transporting patients to distant centers would still create winners and losers. Patients living near transplant programs with short waiting times would see their waiting times increase, while those listing themselves at distant centers would see theirs decrease. Disparities in waiting times would consequently be reduced. Multiple listing is unlikely to become universal, however, because not all patients would choose to — or be well enough to — travel far from home for such a major procedure. Some patients would also be hesitant to receive transplants at distant centers because doing so would create discontinuities in care that could affect the long-term success of their transplant. Nevertheless, it is plausible that a substantial number of patients would choose to be listed at multiple transplant sites if it were logistically and economically feasible to get to more distant centers. Timely transplantation, after all, can mean the difference between life and death. In general, any effort to improve the U.S. health care system must strike a balance between promoting low-cost, high-quality care and promoting local health care systems that are easily accessible to patients, wherever they live. If we are to reduce the current geographic disparities in transplantation, we will need to decide whether to do so within the current system, by paying companies to fly patients to transplant centers that have shorter waiting lists, or by replacing the current system with one in which we fly organs across regional boundaries to align supply more appropriately with patient need. One way or another, I believe, the U.S. organ-transplantation system needs to change. The availability of the benefits of organ transplantation should depend neither on a patients ability to charter a private jet nor on whether he or she is lucky enough to live near a hospital that, thanks to our “local first” system, has a relatively short waiting list. When it comes to lifesaving transplants, geography should not be destiny. Disclosure forms provided by the author are available with the full text of this article at NEJM.org. References Scientific Registry of Transplant Recipients home page (srtr.org). P Ubel, A CaplanGeographic favoritism in liver transplantation.N Engl J Med1999;340:963-965 Institute of Medicine Committee on Organ Procurement and Transplantation Policy. Organ procurement and transplantation: assessing current policies and the potential impact of the DHHS Final Rule. Washington, DC: National Academies Press, 1999. Neergaard L. Mapping a better organ transplant list. Herald-Tribune. August 20, 2013 (health.heraldtribune/2013/08/20/mapping-a-better-organ-transplant-list). RM Merion, MK Guidinger, JM Newmann, MD Ellison, FK Port, RA WolfePrevalence and outcomes of multiple-listing for cadaveric kidney and liver transplantation.Am J Transplant2004;4:94-100 Source Information From the Fuqua School of Business, the Sanford School of Public Policy, and the School of Medicine, Duke University, Durham, NC.
Posted on: Fri, 26 Dec 2014 04:57:50 +0000
Trending Topics
Recently Viewed Topics
© 2015