Thursday, July 19, 2018

Manipulation by doctors of the Organ Allocation System Waitlist Priority

You will be shocked to learn that doctors and transplant centers respond to incentives in their effort to get scarce organ transplants for their own patients...

Here's a recent OPTN/UNOS white paper on the subject, concerning the waitlist for organs (such as hearts) for which physician decisions can influence patients' position on the waitlist.

Manipulation of the Organ Allocation System Waitlist Priority through the Escalation of Medical Therapies

"This white paper provides an ethical analysis of physicians’ practices of escalating care to waitlisted transplant candidates in order to increase their priority in the allocation system. Many in the transplant community perceive, as expressed explicitly in the medical literature23, that this practice of unnecessary escalation of care is widespread, and recognize that physicians may feel compelled to similarly manipulate the waitlist priority system so that their candidates are not disadvantaged as a result of the practices of others.

"For example, in heart transplantation, priority status can be influenced by the degree of therapeutic intervention applied to the transplant candidate, based on the assumption that therapeutic measures are a reliable indicator of disease severity.4 An unintended consequence of this approach is that a physician can raise the priority status of a patient by instituting more advanced therapeutic measures even in the absence of true medical necessity, a tactic some informally refer to as “gaming.”

"Due to the organ shortage, the transplant waitlist “is functionally a zero-sum rationing process.”5 Shortening wait times for some directly increases wait times for others. Thus, the practice of instituting more advanced therapies to shorten an individual’s wait time has no beneficial effect on wait times for the patient population in the aggregate. However, manipulating care to achieve a higher candidate priority can generate complications in candidates receiving such care while also jeopardizing public trust in the organ allocation system, which in turn, could reduce organ donation rates.

"OPTN/UNOS leadership requested an ethical analysis regarding the manipulation of the organ allocation system, particularly as it pertains to medically unnecessary escalation of interventions that are instituted for the sole purpose of increasing a candidate’s waitlist priority. The OPTNhas not previously commented on this issue."

"During the mid-late 1990s, three transplant hospitals in Chicago, IL were alleged by federal and state authorities to have falsely reported patients as critically ill in order to house them in the intensive care unit for the purpose of moving them to the top of the liver transplant waitlist.20 The hospitals denied any wrongdoing, but did receive financial penalties. These incidents generated questions about the integrity and fairness of the liver allocation system based on the alleged events.21,22

"In the last five years, prominent editorials described the widespread use of medical interventions that are not thought to be medically indicated in routine practice, but allow for patients to receive higher waitlist priority.23,24 This includes increased utilization of pulmonary artery (PA) catheters with continuous inotropes for the purpose of increasing the priority status on the waitlist of a patient with heart failure.25 While there are situations in which PA catheter use is appropriate, this intervention is associated with excessive adverse complications, which typically prohibits its routine use. When use of PA catheters was aligned with allocation priority, increasing use of PA catheters quickly followed.26 Further, vascular complications that preclude further catheterization have evolved to become a major justification for Status 1A exceptions, which are presumed to be related to overuse of PA catheters.27,28

"Increasingly, heart transplant candidates are being listed as Status 1A (the highest priority), which is largely based on the intensity and risk of the intervention used to treat the patient. This category was originally intended for potential transplant candidates expected to survive less than one week. Now, it’s not uncommon for Status 1A patients to have longer waitlist survival, and they may wait 6-12 months ."
"Multiple stakeholders stand to gain from manipulating the allocation system, including the candidate and the transplant hospital."

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