Deceased-donor transplants: UNOS in the crosshairs

 There is unprecedented political will aiming towards reform of the system by which organs for transplant are recovered from deceased donors in the U.S. and allocated to patients in need of a transplant.  Here are two opposing views about current proposals to reform or replace the current government contractor in charge of this system, UNOS, the United Network for Organ Sharing..

From NPR:

The Government's Plan To Fix A Broken Organ Transplant System, March 28, 2023

You can listen here:

"For nearly 40 years, the United Network for Sharing Organs (UNOS) has controlled the organ transplant system.

"But that's about to change. Last week, the government announced plans to completely overhaul the system by breaking up the network's multi-decade monopoly.

"For those who need an organ transplant, the process is far from easy. On average, 17 people die each day awaiting transplants. More than 100,000 people are currently on the transplant waiting list according to the Health Resources and Services Administration.

"UNOS has been criticized for exacerbating the organ shortage. An investigation by the Senate Finance Committee released last year found that the organization lost, discarded, and failed to collect thousands of life-saving organs each year.

"Can the government reverse decades of damage by breaking up control? And what does this move mean for those whose lives are on the line?

"The Washington Post's Health and Medicine Reporter Lenny Bernstein, Federation of American Scientists Senior Fellow Jennifer Erickson, and Director at the Vanderbilt Transplant Center Dr. Seth Karp join us for the conversation. Dr. Karp was also a former board member for The United Network for Sharing Organs

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And here's an alternate view, by three professors of surgery at the University of California San Francisco Medical Center, saying that the system isn't badly broken at all, and that attempts to fix it may lead to coordination failures that, at least in the short term, will cause additional problems.

From MedPageToday:

Our Organ Transplant System Isn't the Failure It's Made Out to Be. — Upholding the system will save lives  by Peter G. Stock, MD, PhD, Nancy L. Ascher, MD, PhD, and John P. Roberts, MD, March 24, 2023

"Thanks to a robust network of hospitals, nonprofit organizations, and government support, the U.S. remains a leader in organ transplantation. This community, which is managed by United Network for Organ Sharing (UNOS), saves tens of thousands of lives every year. Despite this success, opponents of UNOS are advocating to dismantle the transplant system as we know it.

...

"As transplant surgeons with a long history of involvement with the system -- including one of us (Roberts) serving as a past Board President of UNOS/Organ Procurement and Transplantation Network (OPTN) -- we have intimate knowledge of both its successes and its shortcomings. While UNOS has room to improve operationally -- and is working to do so -- we clearly see the organization's life-changing results in our operating rooms and offices. More work lies ahead, however, such as addressing the fact that a rising number of organs are recovered but not transplanted.

"Neither UNOS nor organ procurement organizations (OPOs), which facilitate recovery and organ offers to hospitals, have control over whether medical centers ultimately accept and transplant organs into patients. Though the former two have taken all the blame to date, this remains an issue that concerns the entire system. Leaving our nation's transplant centers out of this critical discussion is a serious oversight. For our entire system to save more lives, transplant centers need to have clear organ acceptance criteria, the appropriate resources to process available organs, and the tools and flexibility to utilize organs from more medically complex donors.

...

"The recommendations for division of labor as suggested this week by Carole Johnson, administrator of the Health Resources and Services Administration (HRSA), may be well intentioned but present a significant risk of further fragmentation and negative consequences due to a lack of coordination between government agencies and contractors. This coordination is essential for a functional and successful system. UNOS specifically has been handicapped by a meager budget for years, and despite this has a well-developed system. We believe that given the recent 10-fold budget increase by the Biden administration, the current contractor has the potential to rectify the shortcomings that have been highlighted in the press."

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Earlier posts:

Sunday, August 14, 2022

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

Thursday, March 23, 2023

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

Fox News reports news fulsomely, says Lachlan Murdoch

 Languages, like markets, are human artifacts, although we don't always think of them that way.  And so language can also suffer from coordination failure, when words that mean one thing sound like they mean another, and so over time may be used to mean multiple things, leading to confusion about what is being said.

This is the case with the word "fulsome," which sounds like "full," so that reporting news "fulsomely" might sound to some like reporting it "fully."  (I'll have the dictionary definition at the bottom of this post.)

Here's a story in the Guardian which quotes one of the wealthy owner/managers of Fox Corporation on how Fox news covers the news:

Tucker Carlson firestorm over Trump texts threatens to engulf Fox News.   by Edward Helmore

"So far, Fox is standing by its stars. On Thursday, Lachlan Murdoch, Murdoch’s eldest son, heir apparent and executive chairman and chief executive of Fox Corporation, voiced support for management, its roster of stars and backed Fox New’s editorial standards.

“A news organization has an obligation – and it is an obligation – to report news fulsomely, wholesomely and without fear or favor. That’s what Fox News has always done and that’s what Fox News will always do,” he said.

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And here's the Cambridge Dictionary:

fulsomely

adverb

   formal

US 

 /ˈfʊl.səm.li/ UK 

 /ˈfʊl.səm.li/

 

in a way that expresses a lot of admiration or praise for someone, often too much, in a way that does not sound sincere:

He thanked her fulsomely for her help.

She praised the team's head coach fulsomely.

See

fulsome

In Mirriam Webster, this meaning is now only conveyed in definitions 2-4:

: aesthetically, morally, or generally offensive

fulsome lies and nauseous flattery—William Congreve

the devil take thee for a … fulsome rogue—George Villiers

3

: exceeding the bounds of good taste : OVERDONE

the fulsome chromium glitter of the escalators dominating the central hall—Lewis Mumford

4

: excessively complimentary or flattering : EFFUSIVE

an admiration whose extent I did not express, lest I be thought fulsome—A. J. Liebling
Webster's first definitioin is perhaps what Mr. Murdoch had in mind:

fulsome

adjective

ful·​some ˈfu̇l-səm 

Synonyms of fulsome

1

a

: characterized by abundance : COPIOUS

describes in fulsome detail—G. N. Shuster

fulsome bird life. The feeder overcrowded—Maxine Kumin

b

: generous in amount, extent, or spirit

the passengers were fulsome in praise of the plane's crew—Don Oliver

a fulsome victory for the far left—Bruce Rothwell

the greetings have been fulsome, the farewells tender—Simon Gray

c

: being full and well developed

she was in generally fulsome, limpid voice—Thor Eckert, Jr.

Roundabouts

 A straight line isn't always the safest path between two points.

The Washington Post has the story:

Roundabouts are (slowly!) eating the suburbs by Andrew Van Dam

"Compared with the hundreds of thousands of normal intersections peppering the American landscape, ruled by stop signs and traffic lights, roundabouts are rare beasts. But unlike the drivers they frequently confuse and bedevil, roundabouts are coming on fast.

...

"The modern roundabout relies on a geometric design that forces traffic to slow, plus a simple innovation born in 1960s Britain: the rule that people already in the circle get the right of way. In traditional rotaries and traffic circles, which still lurk in many East Coast cities, traffic moves faster and vehicles already in the circle often must yield to newcomers.

...

"Why add a roundabout, you might ask. Because roundabouts offer impressive safety gains. In general, a roundabout will drive down fatal crashes by 90 percent and cut all car-crash injuries by at least 75 percent, even while accommodating a higher volume of cars.

"At a rural two-way stop, the gains can be even more dramatic. A roundabout can slash all traffic injuries, both fatal and nonfatal, by almost 90 percent. After all, it’s almost impossible to blow through a roundabout at 60 miles an hour and T-bone a minivan — an all-too-common occurrence in typical rural intersections.

“That’s the beauty of the roundabout,” Rodegerdts told us. “It’s the geometry. It’s the curves that are doing the work. And not relying on a traffic-control device as the sole thing keeping you from colliding at high speed.”

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Nevertheless...here's a related NYT story:

The Exceptionally American Problem of Rising Roadway Deaths

Why other rich nations have surpassed the U.S. in protecting pedestrians, cyclists and motorists. By Emily Badger and Alicia Parlapiano

"In 2021, nearly 43,000 people died on American roads, the government estimates. And the recent rise in fatalities has been particularly pronounced among those the government classifies as most vulnerable — cyclists, motorcyclists, pedestrians.

...

"In the 1990s, per capita roadway fatalities across developed countries were significantly higher than today. And they were higher in South Korea, New Zealand and Belgium than in the U.S. Then a revolution in car safety brought more seatbelt usage, standard-issue airbags and safer car frames, said Yonah Freemark, a researcher at the Urban Institute.

"Fatalities fell as a result, in the U.S. and internationally. But as cars grew safer for the people inside them, the U.S. didn’t progress as other countries did to prioritizing the safety of people outside them.

“Other countries started to take seriously pedestrian and cyclist injuries in the 2000s — and started making that a priority in both vehicle design and street design — in a way that has never been committed to in the United States,” Mr. Freemark said.

"Other developed countries lowered speed limits and built more protected bike lanes. They moved faster in making standard in-vehicle technology like automatic braking systems that detect pedestrians, and vehicle hoods that are less deadly to them. They designed roundabouts that reduce the danger at intersections, where fatalities disproportionately occur.

"In the U.S. in the past two decades, by contrast, vehicles have grown significantly bigger and thus deadlier to the people they hit. Many states curb the ability of local governments to set lower speed limits. The five-star federal safety rating that consumers can look for when buying a car today doesn’t take into consideration what that car might do to pedestrians."

A call for capping residency interviews

 One clear symptom that the marketplace for medical residents is in crisis is the persistent drumbeat of suggestions for how to modify it.  The transition from medical school to residency has become congested, with many applications and interviews preceding the centralized clearinghouse known as the Match (which will yield its results on March 19).  

One way to treat a disease is to treat some of its most obvious symptoms. Here's the latest such proposal, to put a cap on the number of interviews. (Readers of this blog will wonder how those will be coordinated, and a number of proposals have been made including signaling, or a centralized interview match.)  

I'm hoping that data will become available to allow these proposals to be better evaluated, and perhaps to allow a market design that will deal with causes as well as symptoms.

Here's the latest, from Medscape.

Fixing the Match Crisis Starts With Capping Interviews  by Helen K. Morgan, MD

"Concern over the so-called "Match crisis" increases every cycle. This year, pandemic-related changes have shined a spotlight on the skewed distribution of interviews. Thanks to the shift from in-person to virtual interviews, applicants were no longer limited by travel and financial concerns. According to some experts, this has resulted in "top" candidates taking additional slots and subsequently reducing opportunities for others.

"Worry about residency interview distribution has surged, with letters of concern posted by the Association of American Medical Colleges and the American College of Surgeons. Before the start of this season, my colleagues and I modeled the potentially dire consequences of ob/gyn applicants "hoarding" too many interviews in an article published in the Journal of Surgical Education.

The residency application problems exposed by the pandemic aren't going anywhere without action. Establishing a cap on interviews is now clearly necessary...."

HT: Mike Rees

Allocating leftover vaccine before it spoils

 The NY Times has the story:

Hunting for a Leftover Vaccine? This Site Will Match You With a Clinic.  More than half a million people have signed up for Dr. B, a service that promises to match them with clinics struggling to equitably dole out extra doses before they expire.   By Katie Thomas

"a New York-based start-up is aiming to add some order to the rush for leftover doses. Dr. B, as the company is known, is matching vaccine providers who find themselves with extra vaccines to people who are willing to get one at a moment’s notice.

"Since the service began last month, more than 500,000 people have submitted a host of personal information to sign up for the service, which is free to join and is also free to providers. Two vaccine sites have begun testing the program, and the company said about 200 other providers had applied to participate.

...

"The company’s database sorts people by local rules about vaccine priority, giving providers better odds of administering their leftover shots to those in the greatest need.

"For many providers, that orderly procedure would be a welcome change from the haphazard systems they are using now. At some pharmacies and supermarket chains, workers have resorted to combing the shopping aisles to find people willing to get a last-minute vaccine. At other locations, vaccine hopefuls wait in line at the end of every shift, which could pose an infection risk, particularly to the most vulnerable."

Coordinating vaccine delivery is hard (California/Blue Cross version)

 The Mercury News has the story:

Santa Clara County will not participate in state’s Blue Shield-run vaccine program  by Maggie Angst

"Santa Clara County said late Monday it won’t take part in the state’s new centralized vaccine distribution system run by Blue Shield — a potentially huge blow to Gov. Gavin Newsom’s highly-touted plan.

"County Executive Jeff Smith said the county would not sign a contract with Blue Shield allowing the health insurance company to take over vaccine distribution in the county, claiming the new oversight wouldn’t do anything to improve vaccination speed or efficiency.

...

"According to officials from Blue Shield and the state, only one county of 58 in the entire state — Kern County — has signed a contract with Blue Shield.

“I think everyone sees it as a solution looking for a problem,” Smith said. “We’re talking about adding bureaucracies rather than vaccinating people.”