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Transplanting Too Soon

Day 3: Surgeons, others see a need for changes

| Tuesday, March 11, 2008
Drs. Steven Rudich and Dr. E. Steve Woodle say the number of transplant surgeries has fallen since Cincinnati's University Hospital stopped doing transplants on less-ill patients. Cincinnati's fewer cases mean nearly $20 million in lost charges annually. Andrew Russell | Tribune-Review
Drs. Steven Rudich and Dr. E. Steve Woodle say the number of transplant surgeries has fallen since Cincinnati's University Hospital stopped doing transplants on less-ill patients. Cincinnati's fewer cases mean nearly $20 million in lost charges annually. Andrew Russell | Tribune-Review

Trying to save lives is not enough.

Liver transplant surgeons said they must balance each patient's survival odds against the vitality of their overall transplant program.

Medicare and Medicaid, the federal reimbursement programs, can prevent patients from going to centers with a low survival rate. Private insurers do the same.

"The problem is, the system gives incentives for getting post-transplant results," said Dr. Richard B. Freeman Jr., transplant surgeon at Tufts-New England Medical Center in Boston. "Systems compete for payers and contracts with insurance companies. Performance is judged by what the post-transplant outcome is."

Changes are needed in the ways transplant programs are evaluated and patients selected for surgery, surgeons and medical plan administrators said.

Among their suggestions:

Credit for the sickest

Centers all are assigned "expected" survival rates by the Scientific Registry of Transplant Recipients, an agency under federal contract to track and analyze transplant data. The rate is based on the mix of patients at each center.

If a center's rates fall below that "expected" survival level, the federal government would do a review of the program and ultimately could stop allowing Medicaid/Medicare patients to go there.

By expecting doctors to save at least eight in 10 patients, the government does not use a realistic measuring stick, said Dr. Amadeo Marcos, former transplant director at the University of Pittsburgh Medical Center. UPMC, at 85 percent, came in just over its one-year "expected" survival rate of 84 percent in the latest reporting period.

"If we're pushing the envelope and so forth, then (the government) has to say, 'Well, in that case, your expected survival should be 50 percent at one year,' " Marcos said. "And that's not happened."

Centers that fall below what's expected are reviewed for special circumstances and are not automatically penalized, said Dr. Jim Burdick, director of the division of transplantation at the U.S. Health Resources and Services Administration.

Thus, he said, the weighting is correct because it reflects the national experience for all transplants, but the government would be open to changes if an individual transplant center makes a good case.

Add 'distance points'

Because of the liver-allocation system, someone in Cleveland could die waiting for a liver, while a compatible organ available in Pittsburgh goes to someone at the very bottom of the transplant list in New Jersey.

The nation's liver allocation system has fault lines among the 11 UNOS regions. Ohio is in Region 10 with Indiana and Michigan, while Pennsylvania is in Region 2 with West Virginia, Delaware, Maryland, New Jersey and Washington, D.C.

Livers are offered to all the patients within a region before they go to sicker patients in other regions.

Rather than allocating livers by region, the Health Resources and Services Administration is looking at adding distance points to MELD scores, Burdick said. Patients closer to the donor liver would have a higher score than those farther away.

Critical patients near the donor organ still would have primary access but the system could reduce situations in which sicker patients in nearby regions are passed over for less-critically ill recipients, he said. Thus, the Cleveland patient, and not the one in New Jersey, would get the Pittsburgh liver.

Expand MELD scores

MELD score could be expanded to include indicators such as sodium level in a patient's blood. A low level indicates fluid retention, a condition known as ascites, and helps predict mortality.

Another indicator could be a patient's liver size, said Dr. Andreas Tzakis, chief transplant surgeon at Jackson Memorial Hospital in Miami. As a patient's condition worsens, the liver scars and can shrink to half its size.

Create a central review board

Liver disease causes problems that are not always reflected in a patient's MELD score, such as cancer, ascites, brain dysfunction, itching and lethargy. Patients can apply to a regional review board for a higher score that would move them up the waiting list.

Results vary by region. Doctors on the review boards can be reluctant to move someone else's patient ahead of their own.

A central national board could be staffed with retired surgeons or people other than active doctors to handle all the applications, Marcos said.

"That is the way to fix this," he said. "Wherever you are in America, you can get a fair and uniform increase in your MELD that will reflect your patient."

With the current system, Marcos said he believes in transplanting livers into patients even if they have been turned down for a higher score.

"If somebody doesn't get the exception points, I don't agree with not transplanting the patient," Marcos said. "Patients should not be hurt by a technicality and a local decision of a review board."

Regional review boards can consider special local circumstances and have an administrative simplicity that allows them to move quickly, Burdick said. Going to a national review system could increase the time to a decision for individual patients.

Most regional decisions are "pretty similar" and the federal government does not see the need for a change, Burdick said.

A minimum score

UNOS came close to saying patients with MELD scores lower than 10 could not appear on the transplant waiting list, but surgeons could not reach a consensus.

Some argued MELD does not reflect a patient's quality of life. Others said patients sometimes need to be on the waiting list before private insurers will pay for related treatments.

"You shouldn't have a patient on the list if a liver came up and you wouldn't transplant them," said Dr. Jeffrey Punch, transplant director at the University of Michigan Medical Center and a regional UNOS director.

A maximum threshold

Some people are so ill they have only a slim chance of surviving transplant surgery, Marcos said. With a limited number of organs, that liver could go to someone with a better chance of living.

"That's something that the transplant community is struggling with, when not to transplant because the patient is too sick," Marcos said. "There's no system in place that says 'Well this is a futile transplant.' "

Define marginal livers

Surgeons disagree about what makes a donor liver bad.

"There is no accurate statistical way to characterize donors," Burdick said.

The Health Resources and Services Administration supports the use of a donor risk index to rate livers according to how well they are expected to work, he said.

As competition for organs increases, aggressive transplant centers try out livers that would have been thrown out before. If they work, that expands the donor pool.

Luis Fábregas can be reached at or 412-320-7998. Andrew Conte can be reached at or 412-320-7835.

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Day 1: MELD 15 hasn't become magic number
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Day 1: Offer of a liver only the beginning of a long road
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Day 2: Treat sickest first, or give livers to the less ill?
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Day 2: 'The sicker they are ... you see a miracle'
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Day 2: Medical ethics issue focuses on 'doing no harm' to patients
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About the data
• Despite a federal rule designed to limit the number of liver transplants in patients who aren't critically ill, four of the nation's 127 programs ...
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