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UIC RESEARCHER AND 'SCIENCE' JOIN ORGAN DEBATE
The Jan. 14 issue of the journal Science includes a summary of a statistical analysis of patients awaiting liver transplants that is helping resolve a two-year public health policy dispute. According to Robert Gibbons, lead author of the Science article, the nation's current organ allocation system fails to meet the needs of the most severely ill patients because it routinely provides transplant organs to lower-risk patients.
Gibbons, a professor of biostatistics in the department of psychiatry and School of Public Health at UIC, conducted the statistical analysis of approximately 68,000 liver patient records as a member of an Institute of Medicine committee. The findings helped make it possible for Donna Shalala, secretary of the Department of Health and Human Services, to strike a deal in November with members of the House and Senate revamping the nation's system for distributing organs. This agreement, Gibbons said, will help ensure that the nation provides organs to the patients who need them most.
The dispute among the Clinton Administration, U.S. Congress and United Network for Organ Sharing over how the nation allocates human organs has been clouded by financial and political considerations, said Gibbons. "It doesn't happen often enough, but rigorous scientific analysis of data can change public policy, even when the debate is very contentious," he added.
Based on the analysis by Gibbons and his colleagues, the Institute of Medicine committee recommended that organs be shared over allocation areas of at least 9 million people. It also recommended that the nation's transplant system be subject to more oversight from the federal government and aided by an independent scientific review board.
The organ allocation dispute began in April 1998 with the publication by the federal health agency of a new regulation, called the "Final Rule." It called for sweeping changes to the United Network for Organ Sharing to alleviate the problem of relatively healthy patients receiving organs while sicker patients die waiting.
The network vigorously objected to the regulation, and Congress asked the Institute of Medicine to conduct a study to review the nation's organ allocation policies and the potential impact of Shalala's proposal. On behalf of the Institute of Medicine, Gibbons and his colleagues on the committee analyzed about 68,000 liver patient records.
The nation currently is divided into 63 local areas, known as Organ Procurement Organizations, serving populations ranging from 1 million to 12 million. These areas, in turn, are grouped into 11 designated regions. OPOs across the country are responsible for distributing human organs in their area. When an organ in an area becomes available, the organization looks for a local match. If no matching patient is found, the organization offers the organ regionally -- and then, in rare instances, nationally.
Patients on the waiting list for organs are classified according to the severity of their illness. Status 1 patients are the most severely ill, with an average life expectancy of one week. Status 2 patients have months to live and are divided into two sub-groups, "A" and "B," depending on the severity of their illness. Status 3 patients need transplants but are not at high risk of death at this stage of their illness.
Gibbons and his colleagues showed that even though Status 1 patients are transplanted at a similar rate across geographic regions, smaller OPOs are more likely than larger ones to transplant Status 2B and 3 patients. This finding, Gibbons said, shows that the current system fails to meet the needs of the most severely ill patients because it routinely uses organs to transplant less severely ill patients in smaller organ procurement organizations.
The study also showed that when organ procurement organizations experimented with sharing donated livers across wider geographic regions, the Status 1 transplantation rate increased from 42 percent to 52 percent and the average waiting time for Status 1 patients decreased from four days to three days. Additionally, the pre-transplant mortality rate decreased from 9 percent to 7 percent. This sharing arrangement decreased the rate of transplantation for less severely ill patients.
Transplant Facts from the IOM Report
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