Health Resources and Services Administration (HRSA) Announces Organ Procurement and Transplantation Network Modernization Initiative.

Here's a long awaited HRSA announcement, indicating their intent to modernize the deceased organ procurement and allocation system in the U.S.  It's still a bit short on details, but specifically mentions budget increases. In the future it will apparently issue Requests for Proposals from organizations willing to bid on parts of the transplantation allocation system, including software. (I hope HRSA is also thinking about how organ allocation policies will be revised and kept up to date in the future, including the possibility of experimenting with proposed improvements on a regular basis.)

The press release:

HRSA Announces Organ Procurement and Transplantation Network Modernization Initiative. Initiative includes the release of new organ donor and transplant data; prioritization of modernization of the OPTN IT system; and call for Congress to make specific reforms in the National Organ Transplant Act

"[March 22, 2023] Today, the Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services (HHS), announced a Modernization Initiative that includes several actions to strengthen accountability and transparency in the Organ Procurement and Transplantation Network (OPTN):

"Data dashboards detailing individual transplant center and organ procurement organization data on organ retrieval, waitlist outcomes, and transplants, and demographic data on organ donation and transplant;

"Modernization of the OPTN IT system in line with industry-leading standards, improving OPTN governance, and increasing transparency and accountability in the system to better serve the needs of patients and families;

"HRSA’s intent to issue contract solicitations for multiple awards to manage the OPTN in order to foster competition and ensure OPTN Board of Directors’ independence;

"The President’s Fiscal Year 2024 Budget proposal to more than double investment in organ procurement and transplantation with a $36 million increase over Fiscal Year 2023 for a total of $67 million; and,

"A request to Congress included in the Fiscal Year 2024 Budget to update the nearly 40-year-old National Organ Transplant Act to take actions such as:

"Removing the appropriations cap on the OPTN contract(s) to allow HRSA to better allocate resources and,

"Expanding the pool of eligible contract entities to enhance performance and innovation through increased competition.

“Every day, patients and families across the United States rely on the Organ Procurement and Transplantation Network to save the lives of their loved ones who experience organ failure,” said Carole Johnson, HRSA Administrator. “At HRSA, our stewardship and oversight of this vital work is a top priority. That is why we are taking action to both bring greater transparency to the system and to reform and modernize the OPTN. The individuals and families that depend on this life-saving work deserve no less.”

"Today, HRSA is posting on its web site at Organ Donation and Transplantation (hrsa.gov) a new data dashboard to share de-identified information on organ donors, organ procurement, transplant waitlists, and transplant recipients. Patients, families, clinicians, researchers, and others can use this data to inform decision-making as well as process improvements. Today’s launch is an initial data set, which HRSA intends to refine over time and update regularly.

"This announcement also includes a plan to strengthen accountability, equity, and performance in the organ donation and transplantation system. This iterative plan will specifically focus on five key areas: technology; data transparency; governance; operations; and quality improvement and innovation. In implementing this plan, HRSA intends to issue contract solicitations for multiple awards to manage and improve the OPTN. HRSA also intends to further the OPTN Board of Directors’ independence through the contracting process and the use of multiple contracts. Ensuring robust competition in every industry is a key priority of the Biden-Harris Administration and will help meet the OPTN Modernization Initiative’s goals of promoting innovation and the best quality of service for patients.

"Finally, the President’s Budget for Fiscal Year 2024 would more than double HRSA’s budget for organ-related work, including OPTN contracting and the implementation of the modernization initiative, to total $67 million. In addition, the Budget requests statutory changes to the National Organ Transplant Act to remove the decades old ceiling on the amount of appropriated funding that can be awarded to the statutorily required vendor(s) for the OPTN. It also requests that Congress expand the pool of eligible contract entities to enhance performance and innovation through increased competition, particularly with respect to information technology vendors.

"HRSA recognizes that while modernization work is complex, the integrity of the organ matching process is paramount and cannot be disrupted. That is why HRSA’s work will be guided by and centered around several key priorities, including the urgent needs of the more than 100,000 individuals and their families awaiting transplant; the 24/7 life-saving nature of the system; and patient safety and health. HRSA intends to engage with a wide and diverse group of stakeholders early and often to ensure a human-centered design approach that reflects pressing areas of need and ensuring experiences by system users like patients are addressed first. As a part of this commitment, HRSA has created an OPTN Modernization Website at OPTN Modernization (hrsa.gov) to keep stakeholders informed about the Modernization Initiative and provide regular progress updates."

************

Here's a related story in the NY Times:

U.S. Organ Transplant System, Troubled by Long Wait Times, Faces an Overhaul. The Biden administration announced a plan to modernize how patients are matched to organs, seeking to shorten wait times, address racial inequities and reduce deaths.  By Sheryl Gay Stolberg

"The Biden administration announced on Wednesday that it would seek to break up the network that has long run the nation’s organ transplant system, as part of a broader modernization effort intended to shorten wait times, address racial inequities and reduce the number of patients who die while waiting.

*****************

 Earlier, the Washington Post had a story about how the most recent (current) version of the system  for allocating deceased donors is indeed having some problems, the most serious of which (in my view) is the congestion  involved in placing an organ for transplant. (This congestion involves time in getting an organ accepted, and then transported...)

New liver transplant rules yield winners, losers as wasted organs reach record high. The number of lifesaving liver transplants has plummeted in some Southern and Midwestern states that struggle with higher death rates from liver disease  By Malena Carollo and Ben Tanen

"New rules requiring donated livers to be offered for transplant hundreds of miles away have benefited patients in New York, California and more than a dozen other states at the expense of patients in mostly poorer states with higher death rates from liver disease, a data analysis by The Washington Post and the Markup has found.

"The shift was implemented in 2020 to prioritize the sickest patients on waitlists no matter where they live. While it has succeeded in that goal, it also has borne out the fears of critics who warned the change would reduce the number of surgeries and increase deaths in areas that already lagged behind the nation overall in health-care access.

...

"The new system, called the “acuity circles” policy, has nearly doubled the median distance livers are transported, increased transport costs and coincided with the highest number of wasted livers in nearly a decade, 949 in 2021. That’s 1 in 10 donated livers. The analysis further shows a significant increase in the number of states sending donated livers beyond their own borders. In 2019, before the new policy took effect, 21 states and territories exported a majority of livers they collected. Two years later, 42 did."

Continuous distribution of deceased donor organs for transplant: proposal and public comment

 Ned Brooks of the National Kidney Donor Organization (NKDO) writes that the comment period is soon ending for proposed changes in the way deceased donor organs are offered.

short videos here https://optn.transplant.hrsa.gov/policies-bylaws/a-closer-look/continuous-distribution/ and 

some additional background and opportunity to submit comments here:    https://optn.transplant.hrsa.gov/policies-bylaws/public-comment/continuous-distribution-of-kidneys-and-pancreata-committee-update/

His concern, and that of other comments visible at the site is whether the priority given to former living kidney donors is being diluted.  (The proposal isn't described in sufficient detail for me to form an opinion on this, or on a number of other matters.)

Liver exchange pilot program at UNOS

 In another step for liver exchange, here's the announcement from UNOS, which recently registered its first patient-donor pair:

UNOS launches first national liver paired donation pilot program

"An innovative approach to matching livers to patients in need aims to increase lifesaving transplants by expanding the number of living liver donations. United Network for Organ Sharing (UNOS) has launched the UNOS Liver Paired Donation (LPD) pilot program, the first nation-wide initiative facilitating liver paired donation matches; the project is led by UNOS Labs in collaboration with transplant and donation professionals from across the country.

"More than 10,000 people are currently waiting for a liver transplant, and increasing paired donation can make a difference. “The community recognized a critical need,” said Ruthanne Leishman, who manages UNOS paired donation programs. “While the idea of swapping livers is new, transplant programs have successfully been swapping kidneys since 2002.” Leishman was part of the UNOS team that initiated the Organ Procurement and Transplantation Network (OPTN) Kidney Paired Donation (KPD) pilot program in 2010, at a time when there were fewer living liver donor transplants. Since that time, living liver donations have become safer and more viable, contributing to the development of living liver donation programs throughout the country. There were 603 living liver donor transplants in the United States in 2022.

"The UNOS LPD pilot program includes 15 experienced transplant programs across the country who have together performed hundreds of living liver transplants over the years. “UNOS Labs has collaborated with a team of some of the most respected transplant professionals in the country. Working with this high caliber of transplant professionals has helped UNOS build a strong program that will increase living donor transplants,” said Leishman.

"While some transplant hospitals have swapped livers within their own or neighboring hospitals, the UNOS LPD program now makes it possible to swap livers across the country. The larger pool of potential living donors means candidates can have increased access to living liver donations, and transplant hospitals have the opportunity to grow their living transplants programs through collaboration.

"The first donor and recipient pair registered in the program are at UCHealth Transplant Center in Aurora, Colo., and are waiting for a match.

“The UNOS LPD program has totally shifted our frame of mind,” says Jaime Cisek, Living Donor Coordinator at UC Health Transplant Center. “It used to be that if someone was incompatible because of their blood type, or there was a significant size discrepancy, then there was no point in working them up. Now, nobody is off the table. Now we’re able to consider that there is somebody out there who is compatible and make that swap.”

"The UNOS LPD program offers living liver donors assistance with both medical and non-medical expenses related to donation, such as travel expenses, lost wages and dependent care. This financial assistance was made possible through a partnership with the National Living Donor Assistance Center (NLDAC) and a generous gift from living liver transplant recipient and UNOS financial supporter David Landes. "

More on UNOS in the hot seat and calls for reform of the U.S. deceased donor transplant system

 Here's another report about the recent Senate Finance Committee hearing about UNOS, which includes a redacted version of the U.S. Digital Service report calling for UNOS's functions to be broken up. (UNOS, the United Network for Organ Sharing, is the federal contractor that runs the U.S. deceased donor transplant system.)

Transplant System Urgently Needs Overhaul, Experts Say— UNOS CEO skewered for alleged failures in management during a Senate Finance Committee hearing by Shannon Firth, Washington Correspondent, MedPage Today

"Members of the Senate Finance Committee and fellow witnesses roasted the head of the United Network for Organ Sharing (UNOS) during a hearing on Wednesday, over what Committee Chair Ron Wyden (D-Ore.) characterized as "gross mismanagement and incompetence."

...

"A report from the U.S. Digital Service issued last year determined that the network lacks the technical capacity to modernize the system. The report recommended that the contract for the system, worth $248 million, be separate from a contract for policy management, according to The Washington Post.

"Sen. Elizabeth Warren (D-Mass.), not one to mince words, told Brian Shepard, CEO of UNOS, "I'll just be clear. You should lose this contract. You should not be allowed anywhere near the organ transplant system in this country. And if you try to interfere with the process of turning the contract over to someone who can actually do the job, you should be held accountable for that."

HT: Frank McCormick

**********

And here is a Senate memo issued just prior to the hearing:

“A System in Need of Repair: Addressing  Organizational Failures of the U.S.’s Organ Procurement and Transplantation Network”

"This bipartisan investigation began in February 2020 when then-Chairman Charles Grassley, then-Ranking Member Ron Wyden, Senator Todd Young, and Senator Benjamin Cardin sent a letter to UNOS expressing their concerns about the adequacy of patient safety standards and belief that OPOs are failing to recover thousands of viable organs each year. 16 The letter also highlighted an investigation by the Department of Health and Human Services, Office of Inspector General (HHS OIG) and news reports, shining a light on “lapses in patient safety, misuse of taxpayer dollars, and tens of thousands of organs going unrecovered or not transplanted,” leading to questions about the adequacy of UNOS’ oversight of OPOs.”17

"In 2021, the investigation continued under the leadership of now-Chairman Wyden and Ranking Member Grassley of the Senate Judiciary Committee with a series of bipartisan requests for information sent to HHS,18 CMS,19 HRSA, and the Office of Management and Budget. Staff also broadened the scope of the investigation to include concerns about the inadequacy of the OPTN information technology system and its impact on patients. 

...

Based on documents and internal memoranda, the Committee found that:

• The OPTN is failing to provide adequate oversight of the nation’s 57 OPOs, resulting in fewer organs available for transplant.

• The lack of oversight by UNOS causes avoidable failures in organ procurement and transplantation resulting in risks to patient safety. These failures include testing procedure errors, transportation issues resulting in life saving organs being lost or destroyed in transit, and process and procedure failures.

• UNOS lacks technical expertise to modernize the OPTN IT system, resulting in risk of system interruption or technical failure with the potential to harm patients across the country."

...

"While not the sole focus of the Committee’s investigation, Senator Grassley and Senator Wyden’s staff also heard concerns from patients, transplant center staff, and OPO staff that UNOS lacks technological expertise or the willingness to develop and maintain an adequate IT infrastructure. Staff also heard concerns that the archaic IT system results in delays in placing organs, organs being discarded, and inaccurate data being used to place organs because of its dependence on staff manually entering hundreds of donor and transplant candidate data points rather than upgrading to systems better able to transfer data across Electronic Medical Record platforms.

"These concerns were validated in a report from the independent U.S. Digital Service (USDS), which is housed within the Executive Office of the President and provides consultation services to federal agencies on information technology.115 The report, titled Lives Are at Stake, states that UNOS has been able to wiggle through and around most new contract requirements for the OPTN technology by hand-waving at change with technical jargon, while making no substantive progress. The USDS also states that:116

• UNOS is incapable of modernizing the OPTN IT infrastructure;

• the core systems are fragile;

• OPTN technology limits policy development;

• UNOS is resistant to change; and,

• OPTN system is dependent on a disjointed and inadequate user experience.

"Ultimately, USDS determined that these technological failings are in fact placing lives at stake and recommended that HHS take action to create a better organ transplant system and enable better patient outcomes, including updating NOTA to create flexibility in how the OPTN is serviced by contractors."

...

"Based on the investigation’s findings, Committee staff makes the following recommendations to improve the OPTN:

• Remove barriers to competition by removing the specific requirement for HHS to contract only with a “non-profit entity that has an expertise in organ procurement and transplantation;”

• Increase the pool of potential bidders by clarifying that the OPTN functions described in NOTA and subsequent amendments may be operated by more than one contractor, since few contractors will have adequate clinical knowledge and expertise in IT, policy development, and data collection and reporting, and policy compliance activities;

• Promote innovation in all OPTN functions (e.g., policy development, compliance and patient safety mentoring, IT infrastructure, coordinating transport of organs, etc.) as the best qualified entities with distinct skill sets could compete for contracts for these functions;

• Remove a major barrier for entry for bidders by providing authority for HHS to procure a government owned, contractor operated modern IT system to facilitate the OPTN functions;

• Increase security and innovation in the OPTN system by ensuring the new IT system is based on current technologies and operated and maintained by a contractor with adequate IT knowledge and experience;

• Ensure the continued viability of the OPTN by authorizing HHS to collect fees from transplant hospitals when adding a patient to the national organ transplant waitlist. This would replace a current fee structure authorized by regulation which is not flexible enough to provide funding for multiple contracts;

• Increase transparency and accountability for chain of custody and transportation of organs procured for transplant by providing for public reporting, as appropriate, on the status of organs in transport; and,

• Increase accountability for organs lost, damaged, or delayed in transport by requiring oversight and corrective action for such incidents.

**********

Earlier:

Wednesday, August 3, 2022

UNOS and organ transplant technology

Thursday, August 4, 2022

UNOS hearing in the Senate

UNOS hearing in the Senate

 Yesterday in D.C. ... a tough hearing of the Senate Finance committee.  You can listen to the video now, but it looks like the committee will populate the links to documents only slowly.

[Update: better video link-- 

https://www.youtube.com/watch?v=iA2wuSN7POs ]

A System in Need of Repair: Addressing Organizational Failures of the U.S.’s Organ Procurement and Transplantation Network

---

Date: Wednesday, August 3, 2022Time: 02:30 PMLocation: 215 Dirksen Senate Office Building

OPEN IN NEW WINDOW

Agenda

---

Pursuant to guidance from the CDC and OAP, Senate office buildings are not open to the public other than official business visitors and credentialed press at this time. Accordingly, in-person visitors cannot be accommodated at this hearing. We encourage the public to utilize the Committee’s livestream of the hearing, available on the website at https://www.finance.senate.gov/. 

Member Statements

---

1.  Ron Wyden (D - OR)
   •  Download Statement
2.  Mike Crapo (R - ID)

Witnesses

---

1. Brian Shepard
   Chief Executive Officer
   United Network for Organ Sharing (UNOS)
   Richmond , VA
   • Download Testimony
2. Diane Brockmeier, RN
   President And CEO
   Mid-America Transplant
   St. Louis , MO
   • Download Testimony
3. Barry Friedman, RN
   Executive Director
   AdventHealth Transplant Institute
   Orlando , FL
   • Download Testimony
4. Calvin Henry
   Region 3 Patient Affairs Committee Representative
   Organ Procurement and Transplantation Network (OPTN)
   Atlanta , GA
   • Download Testimony
5. Jayme Locke, M.D., MPH
   Director, Division Of Transplantation, Heersink School Of Medicine,
   University of Alabama at Birmingham
   Birmingham , AL
   • Download Testimony

Related Files

---

	Report On Organizational Failures Of The United States Organ Procurement
	Exhibit List Of The Report On Organizational Failures Of The United States Organ Procurement
	Appendix A - ABO Incompatibility Case 1
	Appendix B - ABO Incompatibility Case 2
	Appendix C - Cancer Transmission Case 1
	Appendix D - Cancer Transmission Case 1
	Appendix E - Kidney Death Case
	Appendix F - Courier Case 1
	Appendix G - Courier Case 2
	Appendix H - Airline Case 1
	Appendix I - Airline Case 2
	Appendix J - Allocation Error Case
	Appendix K - Donation After Circulatory Death Case 1
	Appendix L - Donation After Circulatory Death Case 2
	Appendix M - Kidney Trash Case
	Appendix N - Financial Allegations Case
	Other Documents Related To The Report On Organizational Failures Of The United States Organ Procurement

 How do I submit a statement for the record?

Any individual or organization wanting to present their views for inclusion in the hearing record should submit in a Word document, a single-spaced statement, not exceeding 10 pages in length. No other file type will be accepted for inclusion. Title and date of the hearing, and the full name and address of the individual or organization must appear on the first page of the statement. Statements must be received no later than two weeks following the conclusion of the hearing.

Statements can be emailed to:

Statementsfortherecord@finance.senate.gov

Statements should be mailed (not faxed) to:

Senate Committee on Finance
Attn. Editorial and Document Section
Rm. SD-219
Dirksen Senate Office Bldg.
Washington, DC 20510-6200

************

Here's a Washington Post story that came out yesterday, while the hearing was in progress:

70 deaths, many wasted organs are blamed on transplant system errors An investigation by the Senate Finance Committee blamed the fatalities on errors in screening organs for disease, blood-type mix-ups and other mistakes  By Lenny Bernstein and Todd C. Frankel August 3, 2022 at 2:30 p.m. EDT

UNOS and organ transplant technology

 Organ transplant  communications and logistics are difficult, and current procedures are clunky. But never attribute to malevolence what can be accounted for by incompetence (and difficulty).

The Washington Post has the story:

Thousands of lives depend on a transplant network in need of ‘vast restructuring’. White House Digital Service found that the technology that matches donated organs to patients has failed repeatedly  By Joseph Menn and Lenny Bernstein

"The system for getting donated kidneys, livers and hearts to desperately ill patients relies on out-of-date technology that has crashed for hours at a time and has never been audited by federal officials for security weaknesses or other serious flaws, according to a confidential government review obtained by The Washington Post.

"The mechanics of the entire transplant system must be overhauled, the review concluded, citing aged software, periodic system failures, mistakes in programming and over-reliance on manual input of data.

"In its review, completed 18 months ago, the White House’s U.S. Digital Service recommended that the government “break up the current monopoly” that the United Network for Organ Sharing, the non-profit agency that operates the transplant system, has held for 36 years. It pushed for separating the contract for technology that powers the network from UNOS’s policy responsibilities, such as deciding how to weigh considerations for transplant eligibility.

...

"UNOS is overseen by the Health Resources and Services Administration (HRSA), but that agency has little authority to regulate transplant activity. Its attempts to reform the transplant system have been rejected by UNOS, the report found. Yet HRSA continues to pay UNOS about $6.5 million annually toward its annual operating costs of about $64 million, most of which comes from patient fees.

...

"UNOS considers its millions of lines of code to be a trade secret and has said the government would have to buy it outright for $55 million if it ever gave the contract to someone else, according to the report.

...

"UNOS oversees what is formally known as the Organ Procurement and Transplant Network, a complex collection of about 250 transplant-performing hospitals; 57 government-chartered non-profits that collect organs in their regions; labs that test organs for compatibility and disease; and other auxiliary services.

"Located in Richmond, UNOS sits at the center of the system. It is the only organization to ever hold the 36-year-old contract to run the operation, currently a multi-year pact worth more than $200 million, funded mainly by fees patients pay to be listed for transplants."

HT: Martha Gershun

***********

My understanding is that the contract is occasionally put out to bid, but that any successful bidder would have to be prepared to operate the whole national deceased organ transplant system immediately from a cold start, which is why the issue of who owns the existing software, data, etc. is important.

Senate Finance Committee subpoenas UNOS

 There's a new sheriff in town in Washington, and Congress is taking note by investigating UNOS, the United Network for Organ Sharing, which is in charge of administering the allocation of deceased organs for transplant.

The United States Senate Committee on Finance yesterday issued the following announcement:

Grassley, Wyden Subpoena the United Network for Organ Sharing as part of Continued Investigation into U.S. Organ Transplant System

Washington – Senate Finance Committee leaders Sens. Chuck Grassley (R-Iowa) and Ron Wyden (D-Ore.) yesterday issued a subpoena to the United Network for Organ Sharing (UNOS), compelling production of documents related to the committee’s investigation of organ procurement organizations (OPOs), and potential false claims submitted to government benefit programs. The Committee determined that issuing a subpoena was necessary in order to receive full and complete production from UNOS.

 

Senators Grassley and Wyden issued the following joint statement:

 “We have serious concerns related to UNOS’ role in overseeing our nation’s OPOs, which have been severely underperforming for decades. Our review has shed light on the improper use of Medicare funds, conflicts of interest and gaps in oversight. UNOS has served as the federal government’s contractor, without competition, since 1986, and is responsible for overseeing the Organ Procurement and Transplantation Network established by Congress. UNOS has indicated they will comply with the subpoena and we look forward to continuing our inquiry.”

 "Senate Finance Committee members began inquiries into organ procurement organizations and UNOS, nearly a year ago. Reports have also detailed various gaps and conflicts in UNOS management of the organ donation system, resulting in a failure to properly ensure an effective system operating on behalf of patients across the country.

 "In November 2020, the Department of Health and Human Services (HHS) issued a Final Rule to impose new transparency guidelines on OPOs. Racial equity experts have lauded these OPO reforms, highlighting that OPOs often provide substandard care to patients of color. And given expert projections that COVID-19 may severely increase the demand for kidney transplants in the coming years, it is more important than ever to ensure the OPO system is functioning effectively and in patients’ interests. 

Deceased donor organs and nautical miles

UNOS has recently announced a new distribution system for deceased kidney and pancreas offers: instead of being offered first to waiting-list patients at transplant centers in the same one of the 58 Donor Service Areas and then one of the 11 OPTN geographical regions as the donor hospital, they will now be offered first to patients on the waiting lists of transplant centers within 250 nautical miles of the donor hospital.

(Why nautical miles? I don't know, but you can read the various proposals that were considered before deciding on 250 of them at this earlier post: Sunday, May 12, 2019  UNOS proposal for public comment: Eliminate the use of DSAs and regions from kidney and pancreas distribution.)

Here is the new (Dec 5, 2019) announcement: 

New policy adopted to improve kidney, pancreas distribution

"Under the newly approved system, expected to be implemented in 2020, kidney and pancreas offers (except for rare, very well-matched donor and recipient combinations nationwide) will be offered first to candidates listed at transplant hospitals within 250 nautical miles of the donor hospital. Offers not accepted for any of these candidates will then be made for candidates beyond the 250 nautical mile distance.

"Candidates also will receive proximity points based on the distance between their transplant program and the donor hospital. Proximity points are intended to improve the efficiency of organ placement by adding priority for candidates closer to the donor hospital. Candidates within the initial 250 nautical mile radius will receive a maximum of two proximity points, while those outside the initial circle will receive a maximum of four proximity points. The point assignment will be highest for those closest to the donor hospital and will decrease as the distance increases.

"Differences from current system and predicted benefits

"The new system will replace a three-tiered approach used since the beginning of national organ allocation policies in the mid-1980s. Currently, most kidney and pancreas offers go first to candidates listed at hospitals within the same donation service area (DSA) where the donor hospital is located. There are 58 DSAs reflecting the assigned service area of organ procurement organizations (OPOs). These DSAs are fixed, often irregular geographic boundaries, and were not set for the express purpose of optimizing organ allocation. In some instances, portions of the same DSA are not contiguous, meaning that some “local” donor matches may travel through service areas belonging to other OPOs.

"Organ offers not accepted at the DSA level currently are made to candidates at hospitals within the same OPTN region as the donor hospital. Finally, offers not accepted at the DSA or regional level are made to candidates listed at transplant programs anywhere else in the United States.

************

One impetus for the move away from geographic allocation within strict borders is because that system was challenged in the courts, see

Friday, December 29, 2017  The courts take an interest in organ allocation rules

Under the new system, arbitrary borders will no longer have such a big effect on access to transplantation. (Except that is for international borders, which are often still insuperable barriers...)

The courts take an interest in organ allocation rules

The rules for how deceased donor organs are allocated to patients needing transplants are set by a long-established, slow and thorough bureaucratic process overseen by UNOS, which typically involves the deliberation of multiple committees and the solicitation of comments from many parties and the public.

Recently the courts have taken an interest however. Here's a story from Modern Healthcare, about a court case brought on behalf of a particular patient in urgent need of a transplant.

As stakeholders debate organ allocation rules, courts may push change

"UNOS, the private, not-for-profit in charge of the organ transplant system, divides the country into 11 regions, essentially demarcating borders within which organs move from donor to recipient.

"The system was abruptly changed as a result of the first legal challenge to these borders in years, which came Nov. 19, in Holman's name.

"Attorneys filed an emergency complaint against HHS on her behalf. They sought an injunction on UNOS' regional policy that is much-debated but seldom changed.

"The Holman lawsuit set in motion a rapid succession of government counter-appeals and new court orders. It culminated in a Thanksgiving change to a rule on lung allocation, expanding the procurement area to a 250-mile radius around a patient's donor service area.
...
"As stakeholders debate the what-ifs, the waitlists in organ-scarce regions aren't getting shorter and patients like Holman and de la Rosa may spur the courts to draw their own conclusions, and possibly their own boundaries."

HT: Frank McCormick
***************

And here's a story on the still-complex current state of affairs for the allocation of deceased-donor livers, from the NY Times:
Greater Access to Donated Livers Promised to Transplant Patients

John Dickerson defends his Ph.D. thesis at CMU, on kidney exchange

John Dickerson will defend today:
Computer Science Thesis Defense, Friday, August 26, 2016 - 2:00pm to 3:30pm
8102 Gates-Hillman Center (or, via Skype, for those of us who are far away).

Here's his summary of what he's preparing to defend:

"The exchange of indivisible goods without money addresses a variety of constrained economic settings where a medium of exchange — such as money — is considered inappropriate. Participants are either matched directly with another participant or, in more complex domains, in barter cycles and chains with many other participants before exchanging their endowed goods. This thesis addresses the design, analysis, and real-world fielding of dynamic matching markets and barter exchanges. We present new mathematical models for static and dynamic barter exchange that more accurately reflect reality, prove theoretical statements about the characteristics and behavior of these markets, and develop provably optimal market clearing algorithms for models of these markets that can be deployed in practice. We show that taking a holistic approach to balancing efficiency and fairness can often practically circumvent negative theoretical results. We support the theoretical claims made in this thesis with extensive experiments on data from the United Network for Organ Sharing (UNOS) Kidney Paired Donation Pilot Program, a large kidney exchange clearinghouse in the US with which we have been actively involved. Specifically, we study three competing dimensions found in both matching markets and barter exchange: uncertainty over the existence of possible trades (represented as edges in a graph constructed from participants in the market), balancing efficiency and fairness, and inherent dynamism. For each individual dimension, we provide new theoretical insights as to the effect on market efficiency and match composition of clearing markets under models that explicitly consider those dimensions. We support each theoretical construct with new optimization models and techniques, and validate them on simulated and real kidney exchange data. In the cases of edge failure and dynamic matching, where edges and vertices arrive and depart over time, our algorithms perform substantially better than the status quo deterministic myopic matching algorithms used in practice, and also scale to larger instance sizes than prior methods. In the fairness case, we empirically quantify the loss in system efficiency under a variety of equitable matching rules. Next, we combine all of the dimensions, along with high-level human-provided guidance, into a unified framework for learning to match in a general dynamic model. This framework, which we coin FutureMatch, takes as input a high-level objective (e.g., "maximize graft survival of transplants over time") decided on by experts, then automatically (i) learns based on data how to make this objective concrete and (ii) learns the "means" to accomplish this goal — a task that, in our experience, humans handle poorly. We validate FutureMatch on UNOS exchange data and make policy recommendations based on it. Finally, we present a model for liver exchange and a model for multi-organ exchange; for the latter, we show that it theoretically and empirically will result in greater social welfare than multiple individual exchanges. Thesis Committee: Tuomas Sandholm (Chair) Avrim Blum Zico Kolter Ariel Procaccia Craig Boutilier (Google/University of Toronto) Alvin Roth (Stanford University)"

He'll be teaching CS at Maryland in the Fall.

Update on the OPTN/UNOS kidney paired donation pilot program through October 2015

Here's a brief update on the UNOS KPD pilot program:
Kidney paired donation pilot program: Five years of lifesaving service, OCT 26, 2015 |

The program "has arranged 155 kidney transplants since its beginning on October 27, 2010. Several more transplants are scheduled to take place over the next several weeks."

That reflects a growing rate of transplants through the UNOS program, which has not yet achieved the volume of other programs, and now accounts for just over 4% of the 3,648 "Paired donation" transplants recorded by the OPTN database. (I'm not sure if those data capture all the kidney exchange chains.)  The majority of kidney exchange transplants in the U.S.  are accomplished through the other multi-hospital kidney exchange networks (NKR and APD), and, increasingly, through exchanges conducted internally by active transplant centers.   

UNOS videos to explain kidney paired donation to potential participants

Here they are, at the top and along the right side of the UNOS KPD page.

KPD video series

Is KPD Right For Me?

• Is KPD Right For Me - Recipient
• Is KPD Right For Me - Donor

KPD Success Stories

• Success Story - Letty
• Success Story - Virginia
• Success Story - Ken & Val
• Success Story - Randy & Joan

The State of the OPTN/UNOS KPD Pilot Program

Here's the report: The State of the OPTN/UNOS KPD Pilot Program, on the kidney exchange program begun by UNOS in 2010.

The report is full of informative figures, but this one tells much of the story: in 2013 the program started to overcome some of  the many logistical difficulties that it faced, and the original market design legacy that had initially limited exchanges to two way exchanges and prohibited and then limiting chains. Here's hoping that the trend will continue: UNOS is a natural home for kidney exchange in that it already deals with all the transplant centers, and that it would be in a position to integrate living and deceased donation (if only it were more nimble in overcoming political and regulatory barriers and embracing best practices...).

UNOS produces a video to inform hospitals about kidney paired donation (kidney exchange)

Video module explains features and benefits of the OPTN kidney paired donation pilot program

Apr 4, 2014 | Committee News, Education, KPDPP, Living Donation, News, Videos

More than half of the eligible kidney transplant hospitals currently participate in the OPTN KPD Pilot Program, but for those that don’t, a video is now available to provide more information.  The video module (8:45) shows how staff members at a transplant hospital decide to join the program. The video overview was created by UNOS staff in close consultation with KPD Work Group leadership. It describes the mission and goals of the program, outlines the benefits of the program for hospitals, and explains how the program increases patient access to transplants.

Contact the KPD Program Manager with questions at kidneypaireddonation@unos.org.

- See more at: http://transplantpro.org/video-module-explains-features-benefits-optn-kidney-paired-donation-pilot-program/#sthash.DNbvVu8D.dpuf

"The module was created by UNOS Instructional Innovations with the goal to provide living kidney donor transplant hospitals, who are not yet participating in KPD, some information about the program.

http://transplantpro.org/video-module-explains-features-benefits-optn-kidney-paired-donation-pilot-program/