The National Academies of Sciences, Engineering, and Medicine (NASEM) on Friday published a report that found the U.S. organ transplant system is "demonstrably inequitable" and recommended several ways to increase fairness and equity, reduce donated organ waste, and improve the system's overall performance.
Currently, more than 106,000 patients in the United States are on the national transplant waitlist, and at least 17 people die each day while waiting for an organ transplant. And although a record number—more than 41,000—of kidney, liver, and other organ transplants were performed last year, many patients who could benefit from transplants are still being overlooked during the process.
In particular, people of color and people with disabilities are significantly less likely to be referred for a transplant or receive a transplant. They are also more likely to spend a longer time on the transplant waiting list. For example, Black Americans are three times more likely to suffer kidney failure than white Americans, but far less likely to be referred for a transplant or ultimately receive one.
In addition, many donated organs often go unused. In particular, around 25% of donated kidneys went unused last year, even though around 84% of patients on the national transplant list are specifically waiting for a kidney transplant.
"While the transplant system does a lot of good things and saves a lot of lives, it is demonstrably inequitable and doesn’t work for enough people," said Kenneth Kizer, chief health care transformation officer and senior EVP of Atlas Research and chair of the committee that wrote the NASEM report. "A lot of things can be done to make the system work better for more people."
In the report, NASEM recommended several ways HHS, which oversees the national transplant system, could create a more equitable, cost-effective, and efficient organ transplantation process for organ donors, patients, and other stakeholders. Some of the recommendations include:
1. Establishing specific national performance goals for the organ transplant system
According to the report, HHS should set specific goals to increase organ donation, procurement, transplantation, and acceptance of offered organs, all of which should be reviewed yearly at a minimum. In particular, HHS should aim to reach 50,000 organs transplanted annually by 2026 and reduce the nonuse rate for donated kidneys from around 20% to 5% or less.
The report also recommends Congress hold HHS responsible for reducing disparities in the organ transplant system within the next five years.
2. Changing the way organs are allocated
Currently, race is considered in clinical equations used to allocate organs. However, race-based thresholds can underestimate disease severity in Black patients, which makes them less likely to get necessary specialty care or be placed on transplant waitlists in a timely manner.
In addition, geographic location can impact how long a patient waits for a donor match and is often used to determine how organs are allocated and whether potentially usable organs are recovered after prospective donors die. Instead of allocating organs based on regional geographic locations, the report recommends allocating organs on a national, continuous basis.
3. Adjusting how kidney transplant waiting time "points" are granted
Currently, the Organ Procurement and Transplantation Network (OPTN), which oversees all organ transplants in the United States, grants allocation "credits" or "points" to patients who accumulate time on a waitlist before they begin dialysis.
However, early referral and acceptance onto a waitlist is not possible for all patients who need a kidney transplant, especially those who have low socioeconomic statuses. To make the allocation of points more equitable, OPTN should grant points based on the date a patient began dialysis instead of when they were put on a waitlist. OPTN should also monitor any unintended consequences of removing pre-dialysis waiting time points.
4. Reducing the nonuse of organs
According to the report, OPTN should make it easier for organ transplant centers to accept organ offers to reduce the nonuse of organs.
Specifically, the report recommends that OPTN require hospitals with transplant centers to better manage their surgical scheduling so organ procurement and transplant operations can take place in a timely manner every day.
In addition, organs at high risk of nonuse should go to transplant centers with a history of being willing to accept and use medically complex organs.
5. Maximizing the use of already available organs
The report also recommends maximizing the use of already available organs while also expanding the current donor pool. In particular, medically complex organs, including organs that were donated after circulatory determination of death, should be prioritized to meet the needs of patients awaiting transplants.
6. Increasing transparency and patient engagement regarding organ offers
HHS should prioritize patient engagement in organ offers and increase transparency about when and why organ offers are declined. According to the report, there are sound medical reasons why an organ should be declined, but patients are not always aware of this information.
HHS should develop, implement, and evaluate methods for transplant teams to communicate with potential recipients about their statuses. In addition, candidates on a waitlist should receive information about the benefits, risks, and alternatives about accepting different types of organs while deciding whether to accept an organ.
7. Establishing donor care facilities
The sooner an organ can be transplanted, the better, which is why the report recommends that all 57 of the country's organ procurement organizations (OPOs) establish and manage donor care facilities. These facilities create decided spaces for deceased donors and their families, make organ procurement more cost-effective, and allow organ procurement to be done in a dedicated surgical facility, reducing complications and delays.
8. Creating a national dashboard of standardized performance measures
Currently, there is widespread variation in the practices and performances of donor hospitals, OPOs, and transplant centers, which can affect quality of patient care. To identify these variations and track the performance of the organ transplant system as a whole, HHS should create a publicly available dashboard of standardized performance measures.
According to the report, the dashboard's metrics should also be meaningful patients and their families, taking into account patient referral for transplant evaluation, time on a waitlist, and quality of life post-transplant. (NASEM press release, 2/25; AP/Modern Healthcare, 2/25)
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