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Transplanting Too Soon

About the data

| Tuesday, March 11, 2008

• 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 have done half of the 846 such transplants since 2005. The programs, by volume of transplants, are Clarian Health in Indianapolis, Pittsburgh's UPMC, Mayo Clinic in Jacksonville and Strong Memorial Hospital in Rochester N.Y. Most other centers do not give livers to less-critically ill patients, except in rare cases. The Trib based its analysis on MELD-score data from the United Network for Organ Sharing, which included exception points awarded to patients with cancer and serious quality-of-life issues.

• Transplants among least ill patients mean big money for medical centers facing increased competition. By doing transplants no one else will do, centers tap into a pool of some 8,900 patients worth an estimated $4 billion in potential charges. They typically get paid the same, no matter how sick the patients are.

• No federal rules exist on the use of marginal or inferior livers for transplantation. Individual surgeons decide whether an organ is suitable. However, when an organ comes from a high-risk donor, physicians are required by federal regulation to make that clear to the patient.

• Liver transplant programs sometimes bypass the sickest patients because their reduced survival odds can hurt overall center success rates.

• Of the 16,000 people on the national liver transplant waiting list, only about 3,400 are so sick that having a transplant would increase their odds of surviving.

• People at the bottom of waiting lists rarely get sicker quickly. Only 5 percent of the 5,800 people in the lowest segment of the list get so sick within a year that they absolutely need a transplant.

The United Network for Organ Sharing, the national clearinghouse for organs, provided data on the annual number of liver transplants performed at each of the United States' 127 liver transplant programs from March 2002 to September 2007.

About the data

Patients on the liver transplant waiting list are ranked by a scoring system called MELD, for Model End-stage Liver Disease. The MELD score estimates their chances of dying from liver disease within three months and ranges from 6 for those least likely to die to 40 for those most likely to die. UNOS sorted the transplants by MELD score, while eliminating pediatric cases and those involving live donors.

The UNOS data includes exception points awarded to patients with cancer or quality-of-life issues not reflected in their biological MELD score. Patients seeking additional points apply to a regional review board, comprised of doctors who decide whether the patient deserves a higher score. That means that if a patient had a biological MELD score of 13, and received exception points to 22, then he or she is listed at time of surgery as being MELD 22.

The Trib's reporting focuses on the number of patients who received transplants at MELD 14 or below. Research from the Scientific Registry of Transplant Recipients says those low-MELD patients have a greater risk of dying within a year of transplant than if they continue to wait.

The purpose of the analysis was to compare centers by the volume of low-MELD transplants they performed. To do this, the Trib:

Added the annual number of transplants by center in two categories: MELD 6 to 14 and MELD 15 to 40.

Divided those sums by the total number of transplants at each center to get the center's percent or volume of low-MELD transplants.

We limited the analysis at this point to centers with at least 20 total transplants in the given time period to eliminate outliers.

In addition to year-by-year calculations, we looked at March 2002 through 2004 and 2005 through September 2007 to analyze the effect of the Share 15 rule, which took effect in 2005 and ensures that more patients with a MELD score of 15 or higher receive first access to donor livers.

We ranked the centers in two categories: by each center's total number of low-MELD transplants for each period, and by volume of low-MELD transplants.

Day 1: How liver surgeries cut short patients' lives
Hundreds of patients each year undergo liver transplants when they don't need them, and possibly never will, a four-month Pittsburgh Tribune-Review investigation found. One ...
Day 1: MELD 15 hasn't become magic number
The nation's liver allocation system had to be fixed. Far too many livers were being taken to transplant centers that were using them on patients ...
Day 1: Offer of a liver only the beginning of a long road
Michael Weekley wanted to wait for the liver transplant. He'd been feeling healthy after years of battling liver disease and told his sister he didn't ...
Day 2: Treat sickest first, or give livers to the less ill?
The father of transplantation felt bewildered. The transplant center bearing Dr. Thomas E. Starzl's name at the University of Pittsburgh Medical Center now does the ...
Day 2: Starzl institute: 'Nobody has a unit like this'
On a recent clinic day at UPMC Montefiore, dozens of liver and kidney transplant patients clogged the seventh-floor waiting room. A man with jaundiced skin ...
Day 2: 'The sicker they are ... you see a miracle'
MIAMI -- Dr. Andreas Tzakis cuts open the woman's belly to reveal her sick liver. Its surface is bumpy and dark pink. "It's supposed to be ...
Day 2: Medical ethics issue focuses on 'doing no harm' to patients
With a limited supply of organs, liver transplant surgeons must worker harder to maintain the guiding principle of doing no harm, medical ethicists ...
Day 3: Surgeons, others see a need for changes
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 ...
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