All rights reserved. Telephone: x Fax: E-mail address: [email protected] The United Network for Organ Sharing UNOS is contracted by the federal government to provide a system for equitable distribution of all organs available for transplantation in the USA. Status 1A candidates 2. Status 1B candidates 3. Status 2 candidates Zone A 4.
Status 1A candidates 5. Status 1B candidates Zone B 6. Status 1A candidates 7. Status 1B candidates Zone A 8. Status 2 candidates Zone B 9.
Status 2 candidates Zone C Status 1A candidates Status 1B candidates Status 2 candidates Local 1. Status 1B candidates Zone A 3.
Status 1A candidates 4. Status 1B candidates Local 5. Status 2 candidates Zone B 6. Committee, which embraces a multidisciplinary group of professionals responsible for the design and monitoring of thoracic organ allocation algorithms.
The first algorithm for the allocation of donor hearts was a 7-tiered medical urgency category system, similar to kidney allocation models. In , the algorithm was simplified and included only two medical urgency categories, Status 1 and Status 2. The major limitation of this system was the inability to allocate organs preferentially to the most critically ill patients.
To overcome this limitation, an allocation policy change in introduced Status 1A and Status 1B. It provides for regional sharing of organs for the most medically urgent patients. Statistical modeling of the waiting list had shown that the most medically urgent patients, those in Status 1A and 1B, benefit the most from heart transplantation. If an appropriate recipient could not be located among those waiting locally, then the heart was offered regionally.
Table 1 compares the old and the new allocation algorithms. Wahlen Veterans Affairs Medical Center. After 2 years of implementation, the full effects of the new APC are unknown.
Our aim was to determine the impact the new allocation policy had on the procurement process, procurement cost, waiting-list mortality, and recipient outcomes. Methods Patients The study included all patients who underwent heart transplantation in the U.
Cardiac Transplant Program. Two eras were selected for comparison, the 2-year era immediately before the APC from July 1, , to June 30, and the 2-year era immediately after the APC from July 1, , to June 30, The study was approved by the institutional review board.
Figure 1 UNOS status at transplantation before and after thoracic organ allocation policy change based on Organ Procurement and Transplantation Network data. Nativi et al. Survival analyses were performed using the Kaplan— Meier method, and survival curves were compared with the log-rank test. Analyses were performed using SPSS software version Figure 2 Total procurement and transportation cost per imported donor organ before and after July based on Intermountain Donor Services data.
Results Eighty patients were transplanted in the pre-APC era. Seventy patients were transplanted in the post-APC era. Graft ischemic time, mean minutes range 3.
Patients with graft ischemic time more than 4 hours, n percentage 29 4. Patients with ventricular assist devices, n percentage 14 5. Length of hospital stay, median days range 10 6. Imported donor hearts, n percentage 43 7. A cost analysis comparing the two eras shows that the transportation cost as well as the total procurement cost per imported donor organ both increased significantly after July Figure 2.
In the pre-APC era, a total of 94 patients were on the cardiac transplant 60— 54— 0. Figure 3 Survival on heart transplant waiting list before and after thoracic organ allocation change based on Organ Procurement and Transplantation Network data.
In the post-APC era, 95 patients were on the waiting list and 5 of them died within 6 months of listing. Short-term posttransplant survival has also not changed significantly. Discussion The intent of the new thoracic organ allocation policy was to decrease mortality on the cardiac waiting list by expanding regional sharing of organs for the sickest patients.
Although the statistical modeling that led to the change was meticulous, the real-life results of any such change are always awaited with some degree of apprehension. The waiting list is not static and it is therefore possible that, with time, the impact of an allocation intervention can change. In addition, the allocation modeling was done on national data, but significant regional differences exist in both the distribution of patients with different urgency status on the waiting list, as well as in the proportion of patients transplanted in the different categories of urgency status in the different regions.
We have not seen a change in mortality on the waiting list. There was a significant increase in the number of heart transplant candidates transplanted in a higher urgency Status 1A and a noticeable decrease in the number of organs allocated to the more stable candidates in the Status 2 category.
These changes were accompanied by a significant increase in average graft ischemic time, and procurement cost. What are the implications of these findings? Our study was not powered to demonstrate changes in waiting-list mortality and this will have to be addressed by analyses of the national OPTN data. We have seen, however, significant changes that did affect the processes of care of patients awaiting heart transplantation.
The change resulted in greater allocation of hearts to patients with higher urgency status. The median waiting time to transplant in a Status 1A patient has increased significantly. In our clinical practice, we can no longer plan on receiving a suitable organ for a patient upgraded to Status 1A within a few days. We believe this is one of the reasons we have also seen a significant increase in the number of patients being bridged to transplantation with ventricular assist devices.
Arguably, compared with transplantation alone, this approach results in excess morbidity, mortality, and markedly higher cost. Although we have not seen a change in short-term mortality, the longer graft ischemic time could still impact long-term survival of the patients. Further, the fact that an increased number of grafts are now being transported over longer distances by air brings two additional considerations. One is the increase in transportation and overall procurement cost that we have documented.
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