Wednesday, November 11, 2015

Organ transplants: rationing by wealth, not health

This study confirms what the data have been suggesting for years---we are rationing transplants by wealth, not health, through permitting patients to be on multiple regional waiting lists, something that requires more money than most patients have.
Registering with more than one organ transplant center appears to give an edge to wealthy patients over those with the most medical need, according to research presented at the American Heart Association’s Scientific Sessions 2015.
Researchers studied the national database of organ donors from 2000 to 2013 and found that patients who simultaneously listed at more than one center had higher transplant rates, lower death rates while waiting, were wealthier and were more likely to be insured.
“It’s an effective approach to address long waiting times and the shortage of organs available for the increasing demand among transplant candidates. But it undermines a bedrock principle of organ transplantation – which is that the sickest people should be transplanted first,” said Raymond Givens, M.D., Ph.D., study lead author and advanced heart failure and transplant fellow at Columbia University Medical Center in New York. “We firmly believe the multiple listing policy needs to be reconsidered.”
Researchers analyzed the United Network for Organ Sharing (UNOS) database, identifying adult patients listed as first-time, single-organ candidates for either heart, lung, liver or kidney transplants. The network is a nonprofit that manages the U.S. organ transplant system under federal contract. UNOS policy allows organ transplant candidates to be listed at multiple centers simultaneously.
Between 2000 through 2013, researchers identified: 33,928 patients waiting for a heart transplant (2 percent were multiple-listed); 24,633 patients waiting for a lung transplant (3.4 percent multiple-listed); 103,332 patients waiting for a liver transplant (6 percent multiple-listed); and 223,644 patients waiting for a kidney transplant (12 percent multiple-listed).
These findings suggest an advantage for wealthier patients who have the money for travel, temporary housing and other costs of multiple listing that are not covered by health insurance, Givens said. Patients with state-run Medicaid generally have lower income and may not have the option to list themselves at a center in a different state.
 Co-authors are Paul Christian Schulze, M.D., Ph.D. and Donna Mancini, M.D. Author disclosures are on the manuscript.
The International Society for Heart & Lung Transplantation and the Heart Failure Society of America funded the study.
And one suspects, this is how Dick Cheney was able to get the donated heart currently beating in his foul chest.

As more people perceive the unfairness of the organ allocation system as it currently exists, there will be increasing reluctance to donate, increasing scarcity. Eliminating multiple listing is not only justified by fairness but by the goal of increasing popular willingness to donate.

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