Federal action could stop unneeded surgeries, experts say
Federal action could stop unneeded surgeries, experts say
By Andrew Conte and Luis Fabregas
TORONTO -- Federal rules need to change to protect patients from receiving
unnecessary liver transplants, leading surgeons said at the American Transplant
Congress here.
"We are concerned," said Dr. Elizabeth A. Pomfret, chairman of the liver and
intestinal organ transplantation committee of the United Network for Organ
Sharing, the federally funded agency that manages the nation's transplant
system. "The new challenge is, can we improve upon the current allocation
system? I think it's very possible that we could."
The Tribune-Review in March reported hundreds of patients each year undergo
liver transplants when they have better odds of living at least a year by
waiting. Often, these people near the bottom of the waiting list receive organs
that were rejected for thousands of sicker patients.
Crediting the Trib with highlighting the problem, UNOS officials are reviewing
the practice and are expected to address the issue at the liver committee
meeting next month.
At last week's transplant congress, a gathering of about 4,500 surgeons,
scientists and other medical professionals discussed the problem and proposed
changes.
Too often, centers perform transplants for the wrong reasons, said Dr. Richard
Rohrer, chief of transplant surgery at Tufts-New England Medical Center.
"There is a huge amount of self-interest," Rohrer said. "There are marketplace
incentives to do these transplants. It's not about the science anymore."
They discussed changes focused on systems for ranking patients and giving out
organs.
Rankings are based on a score called MELD, for Model End-stage Liver Disease,
that predicts whether patients on the waiting list will die within three months
but says little about their life expectancies after surgery.
The system could be changed to favor recipients who have more years to gain from
an organ, said Pomfret, a transplant surgeon at the Lahey Clinic Medical Center
in Burlington, Mass.
The so-called net benefit of a transplant -- the number of years a transplant
recipient could expect to gain from surgery -- could be determined in part by
looking at objective, measurable medical criteria such as the recipient's
disease and age, Pomfret said.
Columbia University researchers have studied a change that would include the
odds of dying within three months after transplant as well as waiting list
mortality.
The review "will allow us to look at low-MELD transplants and figure out if it
makes sense to do them," said Pomfret, adding that she expects some centers will
fight changes to the MELD allocation system.
"There are some centers that will oppose this because they have financial
incentives" to do transplants on low-MELD patients, she said. "That's just a
reality."
Allocation policies need to be revamped, surgeons said.
Too much variation exists among the 11 UNOS regions, said Dr. Russell H.
Wiesner, a liver doctor at the Mayo Clinic in Rochester, Minn. Surgeons in some
regions unnecessarily move people up the list. And, the lack of broader sharing
rules allows less critically ill patients to get organs in some places before
the sickest ones in others.
Patients with low scores can apply to a regional review board for extra points
if they have symptoms such as severe itching, brain disorders or swelling that
are not reflected in their blood work. Those in the region that includes New
York are more likely to be transplanted with the exception points than those in
Pennsylvania or any other region.
Instead, UNOS should create a national review board so that decisions are
standardized across the country, Wiesner said.
"The regional review boards don't work," Wiesner said. "It's a tit for tat. I
hear this all the time."
Under federal allocation policies, geography plays a role in how long patients
wait for livers.
When an organ becomes available, it is offered first to the sickest patients in
that city and then in the region -- but then it is offered to patients lower on
the list, instead of the sickest patients in the next region. An organ could go
to someone near the bottom of the waiting list in Pittsburgh before a dying
patient in Cleveland, because it's in a different region.
That process could be changed to one with wider sharing or one based on donor
density rather than state lines.
Andrew Conte can be reached at andrewconte@... or 412-320-7835. Luis
Fabregas can be reached at lfabregas@... or 412-320-7998.
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