Realizing the Promise of Equity in the Organ Transplantation System (2022) / Chapter Skim
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Immediate or near-term actions include establishing national performance goals, requiring each OPO to establish a donor care unit, increasing the use of procured organs, modernizing information technology infrastructure and data collection requirements, increasing shared decision making with waiting patients, improving the policy development process, sustaining and expanding quality improvement efforts, removing predialysis waiting time "points" from the kidney allocation system, resolving the use of race in the Kidney Donor Profile Index and other clinical equations, and aligning financial incentives with the goal of equity. Longer-term solutions that should begin immediately include extending regulatory oversight of the organ transplantation system to encompass patients needing transplant but not yet on the waiting list.
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. Disparities and inequities in the organ transplantation system are not new and have been a topic of debate and frequent efforts at reform since the United States formalized the national Organ Procurement and Transplantation Network (OPTN)
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. The committee will examine the gaps, barriers, and opportunities for improving deceased donor organ procurement, allocation, and organ distribution to waiting recipients at transplant centers with a keen eye towards optimizing the quality and quantity of donated organs available for transplantation -- in a cost-effective and efficient, fair and equitable manner consistent with the National Organ Transplant Act and the Final Rule.
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CHALLENGES AND OPPORTUNITIES To address its broad charge, the committee focused on three key issues and areas of opportunity for improvement in deceased donor organ procurement, allocation, and distribution -- challenges of inequity in access, variation and inefficiency in system performance, and underuse of donated organs. Challenges of Inequity in Access Getting onto the waiting list -- being listed -- is metaphorically the gateway that must open for one to have access to receiving a transplant of a deceased donor organ.
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organ donors.5 Across transplant centers, the committee found significant variation in the rate at which a center accepts the deceased donor organs offered to individual patients on the waiting list. In both cases, accountability currently does not exist for OPO performance in procuring DCDD organs and transplant center willingness to accept organs suitable for a patient.
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While the behaviors of OPOs and transplant centers can vary significantly across the United States, the policy development process governing how deceased donor organs are allocated to individuals on the waiting list is the purview of the OPTN. The OPTN policymaking process for organ allocation includes extensive committee reviews that aim to involve all stakeholders, but the nature of the reviews contributes to variability in the policy development processes and a general slowness in policy development and implementation.
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-- to realize a more equitable, transparent, cost effective, and efficient system for deceased donor organs: • Develop national performance goals for the U.S. organ transplantation system (Recommenda tion 1)
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To reduce racial and ethnic disparities in the application of kidney transplant alloca tion policies, the OPTN should discontinue the use of predialysis waiting time credit,
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This change would ultimately save more lives in a fairer and more equitable manner by eliminating the current preferential access to deceased donor kidneys for individu als able to gain timely access to referral for transplant and the transplant waiting list. Considerations may be necessary for pediatric transplant candidates, multiorgan trans plant candidates, prior transplant recipients, and those currently listed with predialy sis waiting time.
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HHS should also use the proven capabilities of the highest per forming donor hospitals, OPOs, and transplant centers to establish bold goals to drive national progress toward greater equity, higher rates of organ donation, procurement and transplantation of organs from DCDD donors, and acceptance of offered organs, along with lower rates of nonuse of donated organs, to increase the total number of organs procured and transplants performed. These goals can inform the development and use of various levers of influence including organized programs of quality improvement, payment policies, regulations, technical assistance, and public education campaigns.
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infrastructure and data collection for deceased donor organ procurement, allocation, distribution, and transplantation. HHS should ensure that the OPTN uses a state-of-the-art information technology infrastructure that optimizes the use of new and evolving technologies to support the needs and future directions of the organ transplantation system.
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. Ensuring the success of donor care units at a national level will also require CMS to revise payment incentives for transplant centers such that the transplant center is neither financially punished nor excessively rewarded for performing deceased donor organ management and recovery.
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Recom mended data points needed from donor hospitals, OPOs, referring organizations, and transplant centers are detailed in Figure 7-1. • Create a publicly available dashboard of standardized metrics to provide a com plete human-centered picture of the patient experience -- from patient referral for transplant evaluation, to time on the waiting list, to posttransplant quality of life -- managed by the Scientific Registry of Transplant Recipients (SRTR)
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• Deploy quality improvement techniques that focus on behavior change tools, implementation science, nudging, and education theory to realize uptake of best practices for organ procurement, use, and transplantation across donor hospitals, OPOs, and transplant centers. • Promote the development, systematic sharing, adaptation, and use of best practices in areas such as rapid referral and early response by donor hospitals and OPOs, increasing donation authorization rates among diverse populations, pursuit of all possible organ donors, how to have culturally sensitive conversations with all families about organ donation, intensive waiting list management, successful use of medically complex organs, and how best to communicate with patients about organ offers.
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The OPTN should enhance organ allocation and distribution policies and processes to reduce nonuse of deceased donor organs and make it easier for transplant centers to say "yes" to organ offers. To improve the organ offer process, the OPTN should do the following: • Require the use of more refined filters for transplant centers to indicate their prefer ences for which kidneys will be accepted, if offered.
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HHS should update the OPTN contract to require transplant center accountability for patient engagement and partnership between transplant center professionals and patients in deciding whether to accept or reject an offered organ. The updated OPTN contract should require • Close monitoring of any new transplant center performance metrics to ensure the desired outcomes are achieved and unintended consequences are avoided; • Nudges in the form of reports showing a transplant center's decisions regarding offered organs, as well as comparisons to other transplant centers, to be proac tively developed from SRTR data and shared with individual transplant centers on a monthly basis; and • Transplant programs to document shared decision making that includes a discus sion of survival benefit, relative to staying on the waiting list or dialysis, before deciding to accept or reject an offered deceased donor organ.
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2021. Sex disparity in deceased donor kidney transplant access by cause of kidney disease.
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Current Opinion in Organ Transplantation 26(5)
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