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Eliminate the use of regions in VCA distribution

Proposal Overview

Status: Public Comment

Sponsoring Committee: Vascularized Composite Allograft Transplantation Committee

Strategic Goal 2: Provide equity in access to transplants

Read the proposal (PDF; 1/2019)

Contact: Christopher Wholley


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Executive summary

The OPTN/UNOS Final Rule (hereafter Final Rule) sets requirements for allocation polices developed by the OPTN/UNOS, including sound medical judgement, best use of organs, ability for transplant programs to decide whether to accept an organ offer, avoiding wasting organs, and promoting efficient management of organ placement. The Final Rule also includes a requirement that allocation policies “shall not be based on the candidate’s place of residence or place of listing, except to the extent required” by the other requirements.

On July 31, 2018, the Secretary of Health and Human Services (HHS) found that the use of donation service areas (DSAs) or regions in organ allocation policies cannot be justified under the Final Rule. OPTN/UNOS policies for vascularized composite allograft (VCA) allocation use “region” as the first geographic boundary for distribution. In response to the Secretary’s letter, the OPTN/UNOS Executive Committee directed the VCA Transplantation Committee (Committee) to develop a proposal that replaces “region” with another geographic boundary in VCA allocation policy. This proposal would replace use of regions in VCA allocation policies with a 750 nautical mile (NM) concentric circle around a donor hospital. This will address the Secretary’s findings by allowing efficient placement of deceased donor VCAs, help achieve optimal recipient and graft outcomes, and to reduce the risk of organs being recovered but not transplanted.

This proposal is consistent with Goal Two of the OPTN/UNOS Strategic Plan to increase equity in access to transplant. This project aims to implement rational units for geographic distribution that are more consistent with the requirements of the Final Rule.

Feedback requested

The Committee encourages all interested individuals to comment on the proposal in its entirety. Members are asked to comment on both the immediate and long-term impact on budgets and other resources that may be required if this proposal is approved; this information assists the Board in considering the proposal and its impact on the community. The Committee requests specific feedback on the following items:

  1. Members are asked if they would recommend an alternative distance for VCA distribution, versus the proposed distance of 750 NM? If so, what distance do you recommend and what evidence justifies this distance?

Comments

Kevin Myer | 01/30/2019

LifeGift offers authorized VCAs on every appropriately authorized donor in an effort to support those in need of these grafts.We support the committee recommendation of 750nm in an effort to broaden the "reach" of the OPO when so few candidates are listed. We believe this is consistent with efforts to broaden sharing. We also encourage and highlight the need for more VCA transplant programs in the central and southwest regions of the United States, as our geographic location places us beyond the usual acceptable transportation time limits of the programs with candidates listed, while in our experience, so many families of donors wish to provide these gifts to those waiting, many of whom are wounded warriors.

Region 7 | 02/08/2019

Region 7 vote-6 strongly support, 12 support

Region 1 | 02/18/2019

Region 1 vote-1 Strongly support, 6 support, 5 abstain, 2 oppose, 0 strongly oppose Members commented that unless VCA is programmed in UNet, broader sharing could result in many futile phone calls when trying to place the organs. Some members supported collecting data on organs that are ultimately not transplanted and agreed that it would be helpful to know this when considering broader sharing. Currently, OPOs do not always submit spreadsheets if the organs are not placed so there is no way to capture this data. Several members were concerned about the size of the circle as it related to: cold ischemic time which varies depending on the organ, cost which increases with distance, and method of travel and distribution which is based waiting time. Some of the concern about waiting time was due to a situation where one center in the 750 mile circle has longer waiting times than any of the others, particularly new centers, and will always have more priority on the list. Several members supported a smaller 500 NM circle size to decease cold time and cost and increase efficiency. The region was supportive of encouraging more OPOs to pursue VCA donation.