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Offline Clark

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EDITORIAL: More is better … until it is worse
« on: August 29, 2022, 10:28:07 AM »
https://onlinelibrary.wiley.com/doi/full/10.1111/ajt.17168?campaign=wolearlyview

EDITORIAL: More is better … until it is worse: Can organ placement processes scale to an increasingly complex system?

Joel T. Adler, Syed A. Husain
First published: 11 August 2022 https://doi.org/10.1111/ajt.17168

In recent years, solid organ transplantation in the United States (US) has been characterized by expansion. 2021 saw more waitlist additions, more deceased donors, and more transplants performed than any other year in history (Figure 1).1 There remains immense potential for ongoing growth and systemic improvement via improved organ donation rates, optimization of organ utilization, and increased equity in access to transplant. However, amidst our celebrations of this flood of transplant activity, clear cracks in the allocation system have materialized after removal of donation service area (DSA) allocation borders and the attendant increase in allocation complexity.2 Early systemic evidence abounds: organ discard is rising, as are out-of-sequence organ placements and the delisting of waitlisted candidates in kidney transplant.3, 4
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FIGURE 1

Increasing volume of heart, kidney, and liver waitlist additions, deceased organ donors, and organ transplants performed from 2005 to 2021, based on national registry data.1
In this issue of AJT, Reddy and colleagues provide a firsthand account of how this increasing complexity affects a busy transplant institute's operation by highlighting worsening transplant system dysfunction and organ placement inefficiency.5 In a single-institute study of organ offers from May 2019 to July 2021, the investigators found that the number of kidney offers almost tripled and the number of liver offers more than doubled over a roughly 2-year period encompassing the rollout of both the liver and kidney circle-based allocation systems. Correspondingly, offer-related workload approximately doubled, with surgeons and coordinators each averaging three and four offer-related communications per hour and 9.5 and 19.1 h of offer-related work per week, respectively. Troublingly, the proportion of offers—and associated effort—that involved ultimately discarded organs rose dramatically during this period. While these results may not be generalizable, these data call into question the sustainability of the current organ offer system, especially as the shift toward continuous distribution progresses and as organ procurement organizations (OPOs) respond to regulatory pressure to increase recovery rates.

Although evaluating organ offers is core to the practice of transplantation, the consequences of this allocation inefficiency should not be underestimated. Most importantly, having to process an overwhelming quantity of offers risks worsening suboptimal organ utilization and deviation from written allocation policy. Time spent reviewing and communicating about organ offers is time taken away from patient care and transplant center administrative responsibilities, and transplant centers receive no additional reimbursement to account for the additional effort required to field the burgeoning number of offers. Frequent workflow interruptions increase the likelihood of medical errors. All these factors could contribute to worsening job-related quality of life, threatening to perpetuate the shortage of trainees, in all disciplines, interested in transplantation as a career.

Avoiding these unintended consequences of allocation system changes demands urgent, innovative solutions to reduce the burden on transplant center personnel as we and others have called for. Improved design and widespread use of offer bypass filters could reduce the quantity of offers for organs that centers are unwilling to transplant. More advanced filters may adapt to transplant centers revealed preferences over time, effectively making the Offer Filters Explorer a mandatory requirement. Similarly, better prediction of which organs might be hardest to place may help facilitate “fast-track” offers to centers that have displayed historic willingness to transplant them. Guidance about how many offers an OPO should optimally make to place a particular organ, ideally as decision support in UNet, could reduce time and communication spent on offers; and when these guidelines fail, the number of additional offers can be automatically made. In addition to reducing the total number of organ offers, improving the process of evaluating and responding to individual offers could include optimizing UNet to make donor information easier to find and review and allowing user-level customization of the presentation of donor data. Finally, novel reimbursement schemes for the Organ Procurement and Transplantation Network, OPOs, and transplant centers that can account for the rising burden of organ offers and incentivize more efficient organ placement should be explored.

US organ allocation will undoubtedly continue to become more complex as organ sharing broadens and the regulatory landscape increases its focus on increasing transplant rates, functioning according to all the participants' needs, intentions, and limitations. Pressured by regulatory and system changes, OPOs will recover more organs, transplant centers will decline organs when the logistics become too onerous, and dialysis centers will increase referrals. While broader sharing and continuous distribution is likely to increase geographic equity by normalizing organ availability across the country, it cannot come at the cost of a less efficient system. If that problem is not addressed thoughtfully, some centers who can (and do) adjust to the system will dominate, and the geographic inequity will recur in favor of the best-resourced centers. Increasing efficiency is an opportunity to build equity into our transplant system, and it is incumbent on us to do better at getting organs where they matter most—to our patients.

Unrelated directed kidney donor in 2003, recipient and I both well.
568 time blood and platelet donor since 1976 and still giving!
Elected to the OPTN/UNOS Boards of Directors & Executive, Kidney Transplantation, and Ad Hoc Public Solicitation of Organ Donors Committees, 2005-2011
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