Saturday, August 13, 2016

Gaming the waiting list for a heart transplant

The heart transplant waiting list is game-able, since your place on the list depends on what treatment you are getting. So your doctor can "treat your priority" as well as treat your medical condition.  Here's the story from NPR:
Should Doctors Game The Transplant Wait List To Help Their Patients?

And here's an old (2013) editorial on the subject in The Journal of Heart and Lung Transplantation:
The urgent priority for transplantation is to trim the waiting list by Lynne Warner Stevenson:

"Current definitions of priority levels have been based both on medical rationale and the attempt to protect the system from being “gamed.” When the requirements for inotropic therapy for Status IB and pulmonary artery catheters for Status IA were adopted in the USA, it was with optimism that they would be used only when absolutely necessary to prevent imminent death, because continuous inotropic infusions and indwelling pulmonary artery catheters are inconvenient and costly and have been associated with serious complications. Although individual cases trigger heated controversy in regional committees, it is generally agreed that these therapies are being overused in patients awaiting transplantation.

If high priorities defined by therapies are the only route to access donor hearts, we face conflicted incentives as advocates for our patients. This is serious enough with incentives to inflate the description of severity of illness, but even more serious with incentive to impose interventions with complications, such as indwelling pulmonary artery catheters. One of the major conditions currently cited as justification for Status IA exceptions is vascular complications of indwelling catheters that preclude further catheterization. This complication on the list was virtually never seen before pulmonary artery catheters became an index of priority (although arrhythmia device leads have also added to the vascular complication rate).

The strength of inverse incentives in care of our waiting patients is indexed to the concern that they will die before a transplant, or will develop unnecessary risk such as from cachexia before they finally enter into transplant. The priority status will more truly reflect patient illness when the listing physicians have reasonable confidence that patients will receive a heart in a timely manner, a confidence eroded by the lengthening waiting times, which in turn reflect the anasarca of the waiting list."

HT: Marc Melcher

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