Showing posts with label transplants. Show all posts
Showing posts with label transplants. Show all posts

Sunday, January 21, 2024

Legislative proposals to help living kidney donors

 Martha Gershun brings us up to date on various proposed pieces of legislation to help organ donors and increase access to transplants.

Legislative Efforts to Support Living Kidney Donors,  by Martha Gershun, Guest Blogger

"As a member of the Expert Advisory Panel to the Kidney Transplant Collaborative, I have been honored to provide input during the development of the organization’s priority legislation, the Living Organ Volunteer Engagement (LOVE) Act.  This legislation would help build a comprehensive national living organ donor infrastructure that would support a national donor education program, create a donor navigator system, ensure appropriate donor cost reimbursement, collect essential data, and improve all aspects of living organ donation across the country, substantially reducing barriers that limit participation today.

Key provisions of the LOVE Act would:

  • Provide reimbursement for all direct and indirect costs for living donation, including lost wages up to $2,500 per week.
  • Provide life and disability insurance for any necessary care directly caused by donation.
  • Modify NLDAC rules so neither the recipient’s income nor the donor’s income would be considered for eligibility.
  • Provide for new public education program on the importance and safety of living organ donation.
  • Provide for new mechanisms to collect and analyze data about living organ donation to enable evidence-based continuous process improvement.

Numerous other federal proposals are also currently vying for support to address barriers to living donation on a national level.  They include:

Living Donor Protection Act (H.R. 2923, S. 1384)

  • Prohibits insurance carriers from denying, canceling, or imposing conditions on policies for life insurance, disability insurance, or long-term care insurance based on an individual’s status as a living organ donor.
  • Specifies that recovery from organ donation surgery constitutes a serious health condition that entitles eligible employees to job-protected medical leave under the Family and Medical Leave Act.

Organ Donor Clarification Act (H.R. 4343)

  • Clarifies that reimbursement to living organ donation is not “valuable consideration” (I.e., payment), which is prohibited under the National Organ Transplant Act (NOTA)
  • Allows pilot programs to test non-cash compensation to living organ donors.
  • Modifies NLDAC rules so the recipient’s income would no longer be considered for eligibility.

Living Organ Donor Tax Credit Act (H.R. 6171)

  • Provides a $5,000 federal refundable tax credit to offset living donor expenses.

Honor Our Living Donor (HOLD) Act (H.R. 6020)

  • Modifies NLDAC rules so the recipient’s income would no longer be considered for eligibility.
  • Requires public release of annual NLDAC report.

Helping End the Renal Organ Shortage (HEROS) Act

  • Provides a $50,000 refundable federal tax credit over a period of five years for non-directed living kidney donors.
############
And here's one more, from the Coalition to Modify NOTA



Thursday, December 21, 2023

Cash for kidneys report in the Telegraph

 The Telegraph has this story, by Samuel Lovett, Nandi Theint,  and Nicola Smith. For some reason I can't copy the headline, but the URL is pretty informative: https://www.telegraph.co.uk/global-health/science-and-disease/kidney-organ-trafficking-scandal-private-healthcare-india-myanmar/   3 December 2023 • 9:00am

"One of the world’s biggest private hospital groups is embroiled in a ‘cash for kidneys’ racket in which impoverished people from Myanmar are being enticed to sell their organs for profit.

"India’s Apollo Hospitals, a multi-billion dollar company with facilities across Asia, boasts that it conducts more than 1,200 transplants a year, with wealthy patients arriving for operations from all over the world, including the UK.

"Paying for organs is illegal in India, as it is across most of the world, but a Telegraph investigation has revealed that desperate young villagers from Myanmar are being flown to Apollo’s prestigious Delhi hospital and paid to donate their kidneys to rich Burmese patients.

“It’s big business,” one of the racket’s ‘agents’ told an undercover Telegraph reporter. Those involved “work together to get around the obstacles between the two governments,” she added. The hospital “asks the official questions. And on this side they tell the official lies.”

"The scam involves the elaborate forging of identity documents and staging of ‘family’ photographs to present donors as the relatives of would-be patients. Under Indian and Burmese laws, a patient cannot receive an organ donation from a stranger in normal circumstances.

"Apollo Hospitals said it was “completely shocked” by the Telegraph’s findings and would launch an internal investigation. “Any suggestion of our wilful complicity or implicit sanctioning of any illegal activities relating to organ transplants is wholly denied,” it added.

Tuesday, September 19, 2023

Organ transplantation in China: in transition--and controversy about paying funeral costs

 I recently spoke at the CAST transplant conference in Hong Kong (see picture), and the underlying theme of my talk, and of many talks there, was the transition of transplantation in China, and what its future might hold.

Jie-Fu HUANG is the other speaker on Zoom (to my right and your left), and Haibo Wang is on the far left on stage.

Here are two of my opening slides (using 2021 data from the Global Observatory on Donation and Transplantation)


On the left, you see that, today, China and India already perform more kidney transplants than any country in the world except the U.S.  On the right, you see that, by virtue of their large populations, they accomplish this despite their quite low rates of transplants per million population, compared to the U.S. and countries in Europe.  So if China and India can raise their transplant rates to rates comparable to the U.S. and Europe, most of the transplants in the world will be done in Asia, and many many additional lives will be saved.

Note that China mostly transplants kidneys from deceased donors, while India mostly transplants kidneys from living donors. So they have different paths (and plenty of untapped potential) for raising donation and transplantation rates.  And their paths to their current positions have also been very different.

Here is a recent account reflecting China's recent progress:

Chen, Zhitao, Han, Ming, Dong, Yuqi, Zeng, Ping, Liao, Yuan, Wang, Tielong, et al. (2023). First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China: 5-year Experience at a High-volume Donor and Recipient Liver Transplant Center. Transplantation, 107, 1855-1859. https://doi.org/10.1097/TP.0000000000004561

" In 1972, our center performed the first living donor kidney transplantation in China. Since then, kidney and liver transplant programs have evolved. By the beginning of the 21st century, organ transplantation had advanced, and clinical liver transplants have been performed successfully at the First Affiliated Hospital of Sun Yat-sen University.1

"Organ shortage has been a prominent feature at our institution as it has been around the world. Starting in the early 1980s, many organs had been procured from inmates on death rows. This unethical approach has been rightfully criticized by the worldwide community. As a consequence, the source of organs for transplants has solely been replaced by voluntary donations from Chinese citizens since January 1, 2015.

...

"Moreover, policies and methods for humanitarian aid to donor families were established. Those policies follow WHO guidelines while recognizing specific aspects of the Chinese culture. The State Ministry of Health and the Red Cross Society of China launched a pilot project on organ donation after the death of citizens in 2010 and established the China Organ Donation Committee. The principle of this pilot project was to learn from the experiences and standards in developed countries while recognizing national conditions and the social reality in China aiming to build an ethical and effective scientific organ donation and transplantation system.2

**********

In the same issue of Transplantation as the above article is this invited commentary by Ascher and Delmonico, both former Presidents of The Transplanation Society (of which Transplantation is the official journal). They largely approve of the effort China has made in transplants, but they have a big reservation.

Ascher, Nancy, MD, PhD & Delmonico, Francis. (2023). Organ Donation and Transplantation in China. Transplantation, 107, 1880-1882. https://doi.org/10.1097/TP.0000000000004562

"The date of 2015 is important for the review of any organ transplantation report from China because of the public proclamation in the media in 2015 prohibiting the use of organs from executed prisoners. Clinical transplantation articles antecedent to 2015 have been consistently rejected by Transplantation and the international community because the source of the transplanted organs was most often an incarcerated prisoner. China took a major step to condemn this practice publicly in 2015. However, because there is no law or regulation that prohibits this unethical practice, there has been ongoing concern that this practice may be continuing. Notwithstanding such a reality, there have been regulations that are citable and may be reflective of the changing experience of organ donation and transplantation in China that are consistent with the World Health Organization (WHO) Guiding Principles.

...

"WHAT CONTINUES TO BE OBJECTIONABLE

"The Chinese Red Cross is prominent in the organ donation process and a center of support for deceased donor families designated by the Red Cross as humanitarian aid to donor families.7 However, such humanitarian aid, although not limited to China, should not be misinterpreted to be an effort because it includes payment to elicit consent for donation. The Sun Yat-sen publication suggests that the Red Cross policies follow WHO guidelines while recognizing specific aspects of Chinese culture without elaboration as to the cultural details. A payment to donor families for funeral expenses or other monetary incentives should be recognized as a form of commercialization and would not comply with WHO guidelines."

**********

Some background may help put this objection in perspective. Doctors Delmonico and Ascher are prominent signatories of a declaration that payments to families of organ donors are crimes against humanity (as are payments to living donors, and both are declared comparable to transplanting organs from executed prisoners, and to be organ trafficking. See my 2017 post.)

So, they raise the question of whether saving many lives by increasing deceased donation in China will be justified if it involves paying funeral expenses of donors.  

My guess is that Chinese health authorities, thinking of the many lives to be saved, will think that this act of generosity to families of deceased donors will indeed be justified, taking account of (see above) "national conditions and the social reality in China aiming to build an ethical and effective scientific organ donation and transplantation system." 

Many people in China and elsewhere might even think that little if any justification is needed for generosity, particularly generosity to families of deceased donors, that is to families who are themselves generous.

Friday, February 17, 2023

A tale of two Organ Procurement Organizations, in JAMA Surgery

 Here's a report of two Organ Procurement Organizations with very different rates of recovery of organs:

Variability in Organ Procurement Organization Performance by Individual Hospital in the United States, by Wali Johnson, MD1; Kathryn Kraft, MD2; Pranit Chotai, MD3; Raymond Lynch, MD4; Robert S. Dittus, MD5; David Goldberg, MD6; Fei Ye, PhD7; Brianna Doby, BA8; Douglas E. Schaubel, PhD9; Malay B. Shah, MD2; Seth J. Karp, MD1, JAMA Surg. Published online February 8, 2023. doi:10.1001/jamasurg.2022.7853

"Design, Setting, and Participants  A retrospective cross-sectional analysis was performed of organ donation across 13 different hospitals in 2 donor service areas covered by 2 organ procurement organizations (OPOs) in 2017 and 2018 to compare donor potential to actual donors. More than 2000 complete medical records for decedents were reviewed as a sample of nearly 9000 deaths. Data were analyzed from January 1, 2017, to December 31, 2018.

"Exposure  Deaths of causes consistent with donation according to medical record review, ventilated patient referrals, center acceptance practices, and actual deceased donors.

"Main Outcomes and Measures  Potential donors by medical record review vs actual donors and OPO performance at specific hospitals.

"Results  Compared with 242 actual donors, 931 potential donors were identified at these hospitals. This suggests a deceased donor potential of 3.85 times (95% CI, 4.23-5.32) the actual number of donors recovered. There was a surprisingly wide variability in conversion of potential donor patients into actual donors among the hospitals studied, from 0% to 51.0%. One OPO recovered 18.8% of the potential donors, whereas the second recovered 48.2%. The performance of the OPOs was moderately related to referrals of ventilated patients and not related to center acceptance practices.

"Conclusions and Relevance  In this cross-sectional study of hospitals served by 2 OPOs, wide variation was found in the performance of the OPOs, especially at individual hospitals. Addressing this opportunity could greatly increase the organ supply, affirming the importance of recent efforts from the federal government to increase OPO accountability and transparency.

**********

And here's an accompanying editorial:

It Is Time for the Light to Shine on Organ Procurement Organizations by Robert M. Cannon, MD, MS1; Jayme E. Locke, MD, MPH1 JAMA Surg. Published online February 8, 2023. doi:10.1001/jamasurg.2022.7857

"Many explanations have been put forth as to why some OPOs carry out their mandate more effectively than others. One argument is that mechanisms of death in some parts of the country are more conducive to organ donations than in others. We have refuted this phenomenon as a significant factor in OPO performance variability in our previous work.3 Others have even tried to place the blame for poorly performing OPOs at the feet of “risk-averse” transplant centers, a factor that the data presented in this current study also refute. The cold truth is that we have no good understanding of why some OPOs are better than others, or even what an acceptable level of OPO performance should be, because the environment in which OPOs operate is so completely obscure."

Tuesday, November 29, 2022

Motorcycles as donorcycles

 Here's an article from JAMA Internal Medicine, noting that motorcycle rallies produce an increase in organ transplants.

Organ Donation and Transplants During Major US Motorcycle Rallies  by David C. Cron, MD, MS; Christopher M. Worsham, MD; Joel T. Adler, MD, MPH; Charles F. Bray, BS; Anupam B. Jena, MD, PhD,  JAMA Intern Med. Published online November 28, 2022. doi:10.1001/jamainternmed.2022.5431

"Key Points

Question  Is the incidence of organ donation and transplants higher during major US motorcycle rallies?

Findings  In this cross-sectional study of 10 798 organ donors and 35 329 recipients of these organs from a national transplant registry from 2005 to 2021, there were 21% more organ donors and 26% more transplant recipients per day during motorcycle rallies in regions near those rallies compared with the 4 weeks before and after the rallies.

Meaning  While safety measures to minimize morbidity and mortality during motorcycle rallies should be prioritized, this study showed the downstream association of these events with organ donation and transplants."

***********

Helmet laws by State (only the States in orange require all motorcycle riders to wear a helmet):


I wonder what would happen if some State passed a helmet law saying that adults are free to ride without a helmet, but doing so automatically registers the rider as a willing deceased donor. (Such a law might decrease deceased donation by convincing more riders to wear helmets.)



HT: Alex Chan

Sunday, October 23, 2022

Reforming kidney care, by Drs. Ben Hippen and Thao Pascual.

 Ben Hippen is a transplant nephrologist who I encountered not too long after I started to think about kidney transplants. I've always found it enlightening to listen to him. And he's changed where he sits, most recently by taking a position with Fresenius, the big dialysis provider.

Here's a snippet of his professional history from his cv:

Current positions:

•Senior Vice President, Global Head of Transplant Medicine, Fresenius Medical Care. Sept 2021

•Clinical Professor of Internal Medicine, University of North Carolina, Chapel Hill School of Medicine. (Non-tenure track appointment) April 2015-present.

Past Positions:

•General and Transplant Nephrologist, Metrolina Nephrology Associates, P.A, Charlotte, North Carolina. 2005-2021

•Attending General and Transplant Nephrologist, Transplant Center, Carolinas Medical Center, Charlotte, North Carolina. 2005 - 2021

•Medical Director, FKC Baxter Street Hemodialysis Unit (in-center and home therapies).2009-2021.

Here are some of his current thoughts, with his colleague Dr. Pascual, in Medpage Today on how to advance kidney care and transplantation.

The Kidney Transplant Ecosystem Is Ripe for Reform— Here are the policies and payment systems that need to change  by Benjamin Hippen, MD, and Thao Pascual, MD

"A centralized data repository of patients' clinical evaluations, laboratory, and radiologic testing accessible by multiple transplant centers could reduce the time, expense, and waste of redundant or obsolete testing.

...

"Quality outcomes for transplant programs should be pegged to the patient outcome that really matters: Receiving a successful kidney transplant in the shortest period of time. A recent survey of patients with kidney disease regarding tradeoffs between being transplanted earlier and waiting for a "better organ" confirms that a wide majority of patients prioritize being transplanted sooner. "Transplant soon and well" should be the mantra for regulators and policy makers when considering nephrologist and dialysis provider-facing metrics to achieve the right outcomes for patients. 

...

"several reforms can be made to the transplant ecosystem to make it easier for transplant centers to be more aggressive in their organ acceptance behaviors. Changing the organ offer system to use the approach of "simultaneously expiring offers" can streamline organ placement timelines, placing higher-risk organs with more risk-tolerant centers more quickly and efficiently. Aligned with the goal of getting patients to transplant faster, regulators and payors (public and private) should prioritize shortening time to transplant over sky-high 1-year patient and graft survival thresholds. The lowest performing third of transplant centers are conferring longer and better survival rates to patients compared to any maintenance dialysis therapy. We should seek to remove regulatory and financial barriers to transplant centers seeking to safely make use of every gift of life. If we expect transplant centers to transplant higher-risk organs, we should recognize that it may cost more to perform those transplants successfully. The payment system for transplants should account for these higher costs so that transplant centers are not faced with losing money when transplanting higher-risk organs.

"A key component of the kidney transplant ecosystem is the generosity of living donors, and we should do more to support their decision to give the gift of life. This means protecting living donors from insurer efforts to exclude them from life or disability insurance coverage because of their donation. In addition, enhancing education efforts to increase living donor kidney transplants can help bridge the gap between organ need and supply. One pending solution to these challenges is the passage of the Living Donor Protection Act (H.R.1255/S.377). The bill would prohibit discrimination by insurers based on an individual's status as a living organ donor. Employers can also do their part through adjusting their paid leave policies for employees who become living donors, by joining the AST Living Donor Circle of Excellence."

"Benjamin Hippen, MD, is senior vice president and head of transplant medicine and emerging capabilities at Fresenius Medical Care. Thao Pascual, MD, is associate chief medical officer at U.S. Renal Care. They are both members of Kidney Care Partners."

********

As a long time, thoughtful  observer of kidney care and transplantation, Dr Hippen's point of view has shifted over time. Below are some (much) earlier blog posts featuring some of his earlier thoughts.


Wednesday, March 16, 2011

Monday, September 19, 2022

Crowdsourcing organ transplant ethics

 In Slate, an upbeat article about the ethical issues associated with deceased organ allocation and (before that) access to dialysis, and the benefits and difficulties with crowdsourcing the solutions.  

The Kidney Transplant Algorithm’s Surprising Lessons for Ethical A.I.  A more democratic approach to A.I. is messy, but it can work.  BY DAVID G. ROBINSON

This article is adapted from Voices in the Code: A Story About People, Their Values, and the Algorithm They Made, out Sept. 8 from Russell Sage Foundation Press.

" in the world of organ transplants, surgeons and data scientists have an unusual habit of being brutally honest about the human lives behind their work—of inviting others into the impossible choices their field confronts. For better and worse, the organ transplant system is itself a real-life laboratory of more inclusive, accountable techniques for building and using A.I.—approaches that are now being proposed in U.S. and EU legislation that could cover courtrooms, hiring, housing, and many other sensitive domains.

...

"Where did this culture of moral humility—one that’s now shaping the design of a high-stakes A.I. system—come from?

"Collaborative decision-making about hard ethical choices in kidney medicine began before the digital revolution. It began before there were many kidney transplants. "

After the development of dialysis there were..."just a handful of dialysis machines, ...Whom to save? Scribner and his team were inundated with pleas from dying patients and their doctors.

"Faced with this quandary, Scribner and his colleagues chose to do something extraordinary: They shared their moral burden with the Seattle community they served. Rather than pretending that their technical expertise gave them special moral standing, they chose to be morally modest, and to widen the circle. The doctors still decided who was medically eligible for dialysis. But then, they established a second committee, a group of seven laypeople chosen by the local medical society, who would make the non-medical decision of how to allocate the few available slots among the many eligible patients. The committee members were given some basic education about kidney medicine, but weren’t told how to make their moral choices.

They Decide Who Lives, Who Dies” was the headline of a 1962 Life magazine article about this new group. Its members, who were anonymous, were photographed in shadow. A clerical collar can be seen on one. The lone woman of the group, a homemaker, clasps a pair of reading glasses in her folded hands. The article reported that the committee’s approach was based on “acceptance of the principle that all segments of society, not just the medical fraternity, should share the burden of choice as to which patients to treat and which ones to let die.”

"The Life story described some biases that played out on the committee—they favored male breadwinners who had children to support—and it triggered widespread revulsion. A pair of scholars wrote that the committee was judging people “in accordance with its own middle-class suburban value system: scouts, Sunday school, Red Cross. This rules out creative nonconformists … the Pacific Northwest is no place for a Henry David Thoreau with bad kidneys.” The original Life story never mentioned race, but later reporting suggested the committee had been biased in favor of white applicants. The committee only ran for a few years. Other dialysis facilities used different rationing strategies—including first-come, first-served—and in 1972 Congress passed an extraordinary law to provide dialysis at public expense through Medicare to all patients who needed it. That proved to be a humane, if extremely costly, escape route from the rationing problem that Scribner once faced.

"Along with all its faults, I think the Seattle committee also gave us much to admire. It was profoundly, even uncomfortably, honest about the hard choices at the center of kidney medicine. It refused to pretend that such choices were—or ever could be—entirely technical. And it tried, albeit clumsily, to democratize the values inside a complex, high-tech system. The Seattle physicians and their lay colleagues were rationing a scarce supply of dialysis treatments. But even after Congress provided dialysis for everyone, the shortage of transplantable kidneys was destined to spark similar questions, ones we still face today."


HT: Tom Riley

Friday, September 16, 2022

A milestone and a stepping stone: 1 million U.S. organ transplants

 Here's the story from the AP, about the 1,000,000th transplant in the U.S., a milestone reached last Friday:

US counts millionth organ transplant while pushing for more By LAURAN NEERGAARD September 9, 2022

"The U.S. counted its millionth organ transplant on Friday, a milestone that comes at a critical time for Americans still desperately waiting for that chance at survival.

"It took decades from the first success — a kidney in 1954 — to transplant 1 million organs

...

"Yet the nation’s transplant system is at a crossroads. More people than ever are getting new organs — a record 41,356 last year alone. At the same time, critics blast the system for policies and outright mistakes that waste organs and cost lives.

"The anger boiled over last month in a Senate committee hearing where lawmakers blamed the United Network for Organ Sharing, a nonprofit that holds a government contract to run the transplant system, for cumbersome organ-tracking and poor oversight."

Monday, September 12, 2022

Access to transplantation around the world, at the International Congress of The Transplantation Society (TTS 2022) in Buenos Aires

I'm attending the 29th International Congress of The Transplantation Society (TTS 2022) | Buenos Aires - Argentina, and will speak in the first plenary session, on Access and Transparency in transplantation around the world.  I'll be the third of three speakers:

 Monday, September 12, 2022 – 09:40 to 11:10

Transplantation in a moving world: Migrants, refugees & organ trafficking
Dominique Martin, Australia
Steps towards increasing deceased donation worldwide
Beatriz Dominguez-Gil, Spain
Transplant sufficiency in an unequal world
Alvin E. Roth, United States

Saturday, August 27, 2022

Patient preferences for taking an offered kidney versus waiting for a better one

 Here's a paper whose title announces in its first two words that it's unusual for the transplant literature: "Patient Preferences."   It sensibly asks about preferences for a transplant now versus a long future wait.  That's relevant, because the waiting list for a kidney is often years long.


Patient Preferences for Waiting Time and Kidney Quality, by Sanjay MehrotraJuan Marcos GonzalezKarolina SchantzJui-Chen YangJohn J. Friedewald and Richard Knight, CJASN Aug 2022, CJN.01480222; DOI: 10.2215/CJN.01480222

Visual Abstract

Abstract

"Background and objectives Approximately 20% of deceased donor kidneys are discarded each year in the United States. Some of these kidneys could benefit patients who are waitlisted. Understanding patient preferences regarding accepting marginal-quality kidneys could help more of the currently discarded kidneys be transplanted.

Design, setting, participants, & measurements This study uses a discrete choice experiment that presents a deceased donor kidney to patients who are waiting for, or have received, a kidney transplant. The choices involve trade-offs between accepting a kidney today or a future kidney. The options were designed experimentally to quantify the relative importance of kidney quality (expected graft survival and level of kidney function) and waiting time. Choices were analyzed using a random-parameters logit model and latent-class analysis.

Results In total, 605 participants completed the discrete choice experiment. Respondents made trade-offs between kidney quality and waiting time. The average respondent would accept a kidney today, with 6.5 years of expected graft survival (95% confidence interval, 5.9 to 7.0), to avoid waiting 2 additional years for a kidney, with 11 years of expected graft survival. Three patient-preference classes were identified. Class 1 was averse to additional waiting time, but still responsive to improvements in kidney quality. Class 2 was less willing to accept increases in waiting time for improvements in kidney quality. Class 3 was willing to accept increases in waiting time even for small improvements in kidney quality. Relative to class 1, respondents in class 3 were likely to be age ≤61 years and to be waitlisted before starting dialysis, and respondents in class 2 were more likely to be older, Black, not have a college degree, and have lower Karnofsky performance status.

Conclusions Participants preferred accepting a lower-quality kidney in return for shorter waiting time, particularly those who were older and had lower functional status."

HT: Martha Gershun

Monday, August 22, 2022

Gary Becker's last paper: appropriately, on a monetary market for kidneys (with Julio Elias and Karen Ye, JEBO, 2022)

 Gary Becker, who passed away in 2014, has a new paper, finished by his coauthors Julio Elias and Karen Ye. It recounts how the shortage of transplantable kidneys has only increased as the demand has grown, and the argument for paying donors is as strong as ever.  (In the meantime, the obstacles to that approach haven't vanished.)

The shortage of kidneys for transplant: Altruism, exchanges, opt in vs. opt out, and the market for kidneys*  by Gary S.Becker, Julio Jorge Elias, and Karen J.Ye, Journal of Economic Behavior & Organization, Volume 202, October 2022, Pages 211-226 (Another link to the paper is here, temporarily.)

Abstract: "In 2007 we published a paper on organ transplants that used data from 1990–2005. We proposed a radical solution of paying individuals to donate kidneys, and claimed that this would clean out the waiting list for kidney transplants in a short period of time. In this paper, we revisit the topic, and examine 14 years of additional data to see if anything fundamental has changed. We show that the main altruistic based policies implemented, such as kidney exchanges or opt out systems for organ procurement, have been unable to solve the problem of shortages. Our analysis suggests that, because of the reaction of direct living donors to increases in other sources of donations, the supply curve of kidney transplants is highly inelastic to altruistic policies. In contrast, a market in organs would eliminate organ shortages and thereby eliminate thousands of needless deaths."


Here's the most relevant part of the first footnote:

*"We started working on this paper together with Gary Becker in 2011. In 2012, we presented the paper at the Law and Economics Workshop and the MacLean Center's Seminar Series of the University of Chicago. The paper was unfinished when Becker passed away in May 2014. In this version of the paper, we updated the data and made some additions. The paper preserves all the economic analysis that was developed in the last version that we collaborated with Becker.

"Becker wrote his first article about the organ shortage in 1997, as part of his monthly BusinessWeek Column. The article was entitled How Uncle Sam Could Ease the Organ Shortage. In the article, he “suggest(s) considering the purchase of organs only because other modifications to the present system so far have been grossly inadequate to end the shortage.”

"In the 2000s, Julio Elias collaborated with Becker in a paper that uses the economic approach to analyze the consequences of legalizing the purchase and sale of kidneys for transplants from both deceased and living donors. In 2014, Becker published with Julio Elias a column in the Saturday Essay section of the Wall Street Journal entitled Cash for Kidneys: The Case for a Market for Organs. For Becker, the problem of the organ shortage and finding ways to solve it was a lifelong project. This paper reflects some of his last thoughts on this problem."


Here are their conclusions:

"The current state of the market of kidney transplants is a disaster. Over the last years, the waiting list has grown in over 4000 individuals each year, while transplants have grown by only about 250 per year. The result has been longer and longer queues to receive organs. 4000 patients died each year while waiting 3 and a half years on average for a transplant. According to our estimations, the annual social cost of those who die while waiting for kidney transplants is over $7 billion.

"Neither kidney exchange programs nor opt out systems nor educational campaigns to increase donations from altruistic donors have solved the problem of shortages. The main reason for their mild effects, as we show in this paper, is that the altruistic supply curve of kidney transplants is highly inelastic to these type of policies because of the reaction of direct living donors to increases in other sources of donations.

"The only feasible way to eliminate the large queues in the market for kidney transplants is by significantly increasing the supply of kidneys. The introduction of monetary incentives could increase the supply of organs sufficiently to eliminate the large queues and thereby eliminate thousands of needless deaths, and it would do so without increasing the total cost of kidney transplant surgery by a large percent.

"A market for the purchase and selling of organs would appear strange at first. However, much as the voluntary military today has universal support, the selling of organs would come to be accepted over time. " advantages of accepting payment for organs would eventually become clear, and people will wonder why it took so long for such an ovious and sensible remedy to the organ shortage to be implemented.

***********

Some related earlier posts:

Another take on compensating donors:

Tuesday, August 16, 2022

Kim Krawiec interviews Frank McCormick on the kidney shortage (and how to end it)


Commentary on the  legal monetary market for kidneys in Iran (and how it differs from illegal black markets):

Monday, June 27, 2022

A Forum on Kidneys for Sale in Iran, in Transplant International


The Pontifical Academy of Science says that compensating donors is a crime against humanity:

All my posts on compensation for donors (not just kidney donors) are here.

And here's my 2007 paper on repugnance (that came out in the same issue of JEP as the Becker and Elias paper), and was a first attempt at understanding some of the obstacles that face proposals to compensate donors of kidneys (and other things):


I'm slowly writing a book that will expand on it.

Saturday, August 20, 2022

Returning to your place in the queue following a failed kidney transplant

 Here's a forthcoming paper that proposes that rejections of marginal kidneys could be reduced if recipients were guaranteed a shorter waiting time for a subsequent transplant if a marginal kidney that they accepted failed.

Tunç, Sait, Burhaneddin Sandıkçı, and Bekir Tanrıöver. "A Simple Incentive Mechanism to Alleviate the Burden of Organ Wastage in Transplantation." Management Science (2022).

Abstract: Despite efforts to increase the supply of donated organs for transplantation, organ shortages persist. We study the problem of organ wastage in a queueing-theoretic framework. We establish that self-interested individuals set their utilization levels more conservatively in equilibrium than the socially efficient level. To reduce the resulting gap, we offer an incentive mechanism that recompenses candidates returning to the waitlist for retransplantation, who have accepted a predefined set of organs, for giving up their position in the waitlist and show that it increases the equilibrium utilization of organs whilealso improving social welfare. Furthermore, the degree of improvement increases monotonically with the level of this nonmonetary compensation provided by the mechanism. In practice, this mechanism can be implemented by preserving some fraction of the waiting time previously accumulated by returning candidates. A detailed numerical study for the U.S. renal transplant system suggests that such an incentive helps significantly reduce the kidney discard rate (baseline: 17.4%). Depending on the strength of the population’s response to the mechanism, the discard rate can be as low as 6.2% (strong response), 12.4%(moderate response), or 15.1% (weak response), which translates to 1,630, 724, or 338 more  transplants per year, respectively. Although the average quality of transplanted kidneys deteriorates slightly, the resulting graft survival one-year post transplant remains stable around 94.8% versus 95.0% for the baseline. We find that the optimal Kidney Donor Profile Index score cutoff, defining the set of incentivized kidneys, is around 85%, which coincides with the generally accepted definition of marginal kidneys in the medical community."

Sunday, August 14, 2022

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