The time has come to let you know about a disturbing proposal to change the process that determines which patients suffering from liver failure will receive donated livers, a shift that would literally have life-or-death implications.
The proposal comes from the Liver and Intestine Committee of the United Network for Organ Sharing (UNOS), the membership group to which all transplant programs belong and that administers the federally mandated Organ Procurement and Transplant Network under contract to the federal government. Leaders of University of Iowa Health Care have significant concerns regarding this proposal and the impact the plan would have on Iowans and other people in the region we transplant.
On the surface, the proposal is designed to decrease the “geographic disparity” that exists across our nation in the ability to obtain a liver transplant. There are many problems with the proposal, including the actual model used to test the theory, the data used in the model, and the very essence of the problem that UNOS is trying to solve. At its core, the modeling predicts that donated livers will shift from regions that do a good job of identifying organs for transplant and shift them to transplant centers in regions that do not. Specifically, organs will move from the Midwest and South to the Northeast. The current proposal is likely to lead to a host of undesired and, unfortunately, predictable outcomes.
The leadership of UI Health Care strongly opposes this proposal that is out for public comment. The model estimates an approximate 15 percent reduction in liver transplantation in Iowa at our program. This will have a profound impact on Iowans who look to the University of Iowa Hospitals and Clinics as the only liver transplant program in the state. The proposal would also lead to more transportation of organs and recovery teams, resulting in higher costs of organ transplants in general.
Patients with a lower socio-economic status will be especially affected because they cannot seek services outside of the state due to Iowa Medicaid Managed Care limitations. There are excellent data that suggest the further a patient is located away from a liver transplant center, the much less likely they are to access a waitlist, receive a transplant, and survive. The University of Iowa serves a largely rural population of patients who would be greatly disadvantaged, if, as predicted, the net effect of the proposed policy would be to ship livers out of the area where they are donated. Furthermore, this disconnects the local link between organ donation and the community where transplantation occurs: through the dedicated educational efforts of The Iowa Donor Network, nearly one-third of Iowans are registered organ donors.
Perhaps the most fundamental failure of the proposed policy, in our opinion, is its lack of an overarching philosophy for liver allocation. Reducing geographic disparity is a noble goal, but perhaps not an achievable one over vast distances where other disparities exist in health, wealth, population density, insurability and access to health care in general. Are we trying to: Transplant the sickest first? Achieve the best outcomes with the limited numbers of organs we have? Achieve the best value (that is, some measure of outcome over some measure of cost)? Or be the most fair — equalize some disparity? Without a stated goal, what we are left with are a set of competing priorities. Much like the business world, having multiple competing strategies is like having no strategy at all.
One thing many of us in the transplant community strongly believe is that part of the solution to this problem is to have more organs to allocate. Working closely with our colleagues in organ procurement organizations to improve the outcomes of those that are underperforming would be far more effective than reallocating organs from those that are doing well. Shifting organs from areas that are performing well and rewarding those that underperform harms patients in our region.
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It’s clear that the lives are Iowans are at stake. They and their loved ones would welcome your support. Please go online today and leave your comment. Make your voice heard by commenting on the proposed policy online.
• Dr. Alan Reed is director of the University of Iowa Organ Transplant Center