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Date: July 20, 1999
Contacts: Cheryl Greenhouse, Media Relations Consultant
David Schneier, Media Relations Assistant
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Organs Should Be Allocated Based on Medical Need
Across Wider Geographic Areas

WASHINGTON -- Organs donated for transplantation should be made available across geographic areas made up of large numbers of people, to enhance the prospects that the organs will be allocated to patients with the most urgent medical needs, says a new report from the Institute of Medicine (IOM).

"The current system of organ procurement and allocation works reasonably well, but significant improvements in both its fairness and its effectiveness could be made," said committee chair Edward Penhoet, dean, School of Public Health, University of California, Berkeley. "The committee strongly believes that the federal government should provide oversight and review of the organ procurement and transplantation system with a focus on assuring that the system is equitable, is grounded on sound medical science, and always places the highest priority on the needs of the patients it serves."

In 1998 the U.S. Department of Health and Human Services (HHS) published a new regulation, setting the ground rules for organ procurement and allocation in the United States. Congress suspended implementation of the regulation, asking the IOM to study its possible ramifications on organ donation rates, equitable access to transplantation, and costs. The committee focused its attention primarily on issues relating to the policies and data concerning liver procurement and allocation, because those were at the center of the debate leading up to the committee's study.

Today, organ procurement organizations coordinate activities that relate to organ procurement and allocation within a defined area, covering populations ranging from about 1 million to 12 million people.

After a comprehensive assessment of the data for 68,000 patients on waiting lists for livers from 1995 to 1999, the committee found that organ procurement organizations serving larger populations are associated with improved access for patients most in need of a transplant and with lower mortality rates following transplantation. For that reason, livers should be allocated over an area large enough to serve at least 9 million people. This area should not be so geographically broad as to pose difficulties in transporting organs, which threatens the viability of the livers themselves. The allocation areas for other organs may differ depending on how long they can remain viable outside the body.

Supply and Demand

Nearly 21,000 Americans received a transplanted kidney, liver, heart, lung, or other organ in 1998. The number of transplants performed has risen in recent years, but demand continues to outrun supply. About 62,000 people presently are waiting for an organ, and 4,000 Americans died last year before they could get one.

The committee determined that one critical assumption in the ongoing transplantation debate is misleading. Geographic variability in the amount of time that patients must wait for a transplant was thought to be a good indicator of how well the system is performing. Based on a thorough review of waiting times for liver transplants, however, the committee found that those with the highest medical need actually wait for a comparable period of time at sites around the country.

However, the transplantation rates do vary for patients who are not as ill, depending on the size and location of the organ procurement organization that serves the transplant center at which the patient is registered. Moreover, patients who are less ill sometimes receive transplants before more severely ill patients who are served by a different organ procurement organization.

Low-income patients, regardless of their racial and ethnic backgrounds, are less likely than affluent white patients to be referred for evaluation because they often do not have access to health insurance and high-quality health services, the committee said. However, once patients are referred for an organ transplant, there appear to be no disparities in acceptance to a waiting list, or in access to transplantation.

Wider Geographic Areas

The committee's analysis addressed a number of concerns raised by the HHS regulation, including fears about reduced access to organs by low-income and minority patients, decreased donation rates, and increased costs associated with the new guidelines.

There is no evidence that the agency's proposed regulation would reduce access to organs for transplantation by minorities, people with low incomes, or people living in remote locations, the committee said. Some have feared that the regulation may result in closure of smaller transplant centers, but the evidence is inconclusive.

Distributing organs across a wider geographic area also is not likely to drive down organ donation rates, as some have speculated. The committee found little or no evidence that people or families would decline to donate, or that health professionals involved in organ procurement would be less diligent in their efforts, if they knew a donated organ would be used outside the donor's immediate geographic area.

Increasing the geographic area for organ distribution may result in a more expensive system, because of increased transportation costs and higher costs associated with transplants for sicker patients. The magnitude of cost increases will depend on how the regulation is implemented and how the practices of transplant centers change over time. The committee noted, however, that cost increases would be relatively minor compared to the total cost of transplantation and would likely be outweighed by the improved health benefits from the new allocation rules.

A More Active Federal Role

To improve the system, the federal government must play a more active role in the review and oversight of organ transplantation. Among other steps, HHS should establish better performance measures for determining how effectively the system is working. And it should create an independent, multidisciplinary scientific review board to provide guidance on how the organ procurement and transplantation system can best serve the public interest.

A committee roster follows. The study was funded by the General Accounting Office and the Greenwall Foundation. The Institute of Medicine is a private, nonprofit organization that provides health policy advice under a congressional charter granted to the National Academy of Sciences.

Read the full text of Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rulefor free on the Web, as well as more than 1,800 other publications from the National Academies. Printed copies are available for purchase from the National Academy Press Web site or at the mailing address in the letterhead; tel. (202) 334-3313 or 1-800-624-6242. Reporters may obtain a pre-publication copy from the Office of News and Public Information at the letterhead address (contacts listed above).

Division of Health Sciences Policy

Committee on Organ Procurement and Transplantation Policy

Edward D. Penhoet, Ph.D. (chair)
School of Public Health
University of California

Naihua Duan, Ph.D. *
Statistics Group
RAND Corp.
Santa Monica, Calif.

Nancy Neveloff Dubler, LL.B.
Director, Division of Bioethics
Montefiore Medical Center, and
Professor of Bioethics
Albert Einstein College of Medicine
New York City

Charles K. Francis, M.D. 1
Charles R. Drew University of Medicine and Science
Los Angeles

Robert D. Gibbons, Ph.D.
Professor of Biostatistics
Departments of Biostatistics and Psychiatry
University of Illinois

Barbara Gill, R.N., M.N.
Clinical Nurse Specialist
Abilene Cardiothoracic and Vascular Surgery of Texas

Eva Guinan, M.D.
Associate Professor of Pediatrics
Dana-Farber Cancer Institute
Harvard Medical School

Maureen Henderson, M.D., D.P.H. 1
Professor Emeritus of Epidemiology and Medicine
University of Washington

Suzanne T. Ildstad, M.D. 1
Institute for Cellular Therapeutics
University of Louisville
Louisville, Ky.

Patricia A. King, J.D. 1
Carmack Waterhouse Professor of Law, Medicine, Ethics, and Public Policy
Georgetown University
Washington, D.C.

Manuel Martinez-Maldonado, M.D. 1
Vice Provost for Research and Professor of Medicine
Oregon Health Sciences University

George E. McLain, M.D.
Assistant Chief of Anesthesiology
Martin Memorial Medical Center
Stuart, Fla.

David Meltzer, M.D., Ph.D.
Assistant Professor
Section of General Internal Medicine, Department of Economics, and Harris School of Public Policy Studies
University of Chicago

Joseph E. Murray, M.D. 1,2
Professor of Surgery, Emeritus
Harvard Medical School

Dorothy Nelkin 1
University Professor
Department of Sociology and School of Law
New York University
New York City

Mitchell W. Spellman, M.D., Ph.D. 1
Director of Academic Alliances and International Exchange Programs
Harvard Medical International
Harvard Medical School


Andrew Pope, Ph.D.
Study Director

* Committee member until May 6, 1999
1 Member, Institute of Medicine
2 Member, National Academy of Sciences