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Optimizing Usage of Kidney Offer Filters

eye iconAt a glance

Background

Offer filters are a tool that transplant programs can use to bypass organ offers they would not accept. Offer filters were tested during two pilot programs and released nationally in January 2022. Currently, offer filters are used on a voluntary basis for kidney offers, but they are being developed for all organs. This concept paper provides an update on the ongoing work on kidney offer filters and seeks to increase community awareness on the benefit of using offer filters. Additionally, this concept paper introduces two offer filter options to increase usage.

Supporting media

Presentation

View presentation

Proposed concept

  • Overview of the offer filters concept
  • Analysis of pilot program and national rollout of voluntary kidney offer filters
  • Introduce two offer filter options for community feedback and consideration:
    • Default Offer Filters: automatically enable filters by default. Kidney programs would not receive offers from donors that meet these default filter criteria unless they specifically opt-out and disable the filter(s).
    • Mandatory Offer Filters: Make offer filter usage mandatory based on what kidneys a transplant program accepts, but allow for a change in offer filter criteria if a transplant program can show a change in acceptance behavior.

Anticipated impact

  • What it's expected to do
    • Increase awareness and promote usage of offer filters
    • Improve efficiency by reducing the number of organ offers OPOs need to make, and that kidney transplant programs need to respond to
    • Decrease the amount of time to allocate an organ and decrease cold ischemic time
    • Increase organ acceptance, especially for hard to place organs
  • What it won't do
    • This concept paper is not a policy change, but will help inform the Operations and Safety Committee on a possible future policy change

Terms to know

  • Offer Filters: a tool that transplant programs can customize in order to not receive organ offers from donors they would not accept organs from.
  • Cold Ischemic Time: the amount of time an organ is not connected to blood flow between organ recovery and transplant.

Click here to search the OPTN glossary

eye iconComments

OPTN Transplant Administrators Committee | 09/29/2022

The Transplant Administrators Committee thanks the Operations and Safety Committee for their efforts in developing this concept paper. A member commented that some of the filters are not addressing the issues that her program experiences. The member pointed out that there are certain types of patients that her center wants to capture in the donor pool, so application of these filters should allow those patients to be easily identifiable. This would include the option to exclude certain patients from the filters applied that would warrant a broader offer range. There were no further comments from the Committee.

American Nephrology Nurses Association (ANNA) | 09/29/2022

ANNA supports this concept paper and encourages more centers to use this feature. We support improving efficiency and minimizing Cold Ischemic Time.

National Kidney Foundation | 09/28/2022

The National Kidney Foundation thanks OPTN for the opportunity to provide feedback on the concept paper on the usage of kidney filters. Please review our attached comment letter. Thank you.

Attachment

Region 6 | 09/28/2022

During the discussion some attendees recommended having more granular filters available. Another attendee agreed and added the filters should have combinations of multiple different factors. One attendee commented that if there are mandatory filters, centers should be able to change them prior to showing behavior that would support the filter change; behavior could then be analyzed after the filter change, and modified if expected behaviors are not met. Some attendees noted that pediatric lists are so small that pediatric centers should not be required to set filters. One attendee recommended a provision for new programs in terms of understanding behaviors since it takes time before you can risk adjust and take on new practices. There was also concern that if the filters were mandatory it could affect smaller programs to a larger degree as they have fewer offers. Another attendee recommended that if the filters are mandatory, centers should be able to change them quickly as they acquire new technology or implement new policy changes. One attendee commented that for adult centers seeing hundreds of offers, the filters would be a good tool for eliminating offers they would not use. They added that they did not support mandatory filters since there are always patient exceptions. Another attendee supported a small number of mandatory filters as long as there was an easy process for when centers want to make preemptive practice changes due to new surgeons, adding the use of NRP, etc. Programs should not have to wait 6 months to attempt to increase organ offers. We should consider allowing centers to modify mandatory filters based on modeling criteria and transplant center preference. One attendee recommended allowing centers to modify mandatory filters based on modeling criteria and transplant center preference. Another attendee noted that implementing filters would expedite getting hard to place organs to programs who will accept them.

OPTN Membership & Professional Standards Committee | 09/28/2022

The OPTN Membership and Professional Standards Committee (MPSC) appreciates the opportunity to provide feedback on the OPTN Operations and Safety Committee’s concept paper Optimizing Usage of Offer Filters. Committee members expressed several concerns with mandatory offer filters, such as difficulty with changing the filters when new physicians or surgeons are hired, when the environment of the transplant program changes, or when there are changes in technology. Members also emphasized the importance of educational materials to enhance transparency for patients and for programs to specifically review the offers that they are not receiving because of the filters. A member inquired if labelling offers would be just as effective as offer filters, and then programs could still see all the offers.

Region 10 | 09/28/2022

Members in the region are supportive of offer filters, with some having success using the current kidney offer filters. However, many in the region are opposed to mandatory offer filter usage without the ability to change the filters for each program. Additionally, many members highlighted the need for customizable filters on the individual candidate level. Every candidate is different, so there needs to be a way to turn off certain filters for candidates who may not receive many offers, like pediatric or high CPRA candidates. Additionally, it was noted that the data used to program the current filters is from June 2021, the data needs to be updated on a regular basis in order to optimize the filters. Others noted support of mandatory offer filter usage because if it is left as voluntary only a handful of programs will use them. If it is made mandatory there should be a mechanism for programs to be able to turn certain filters if their acceptance practices change. Another member noted that the OPTN should require some filters to be used, but avoid mandating all automatic filters. The programs should be encouraged to use the remaining filters, but not mandated. One member added that there already exists an Offer Filters Explorer tool in UNet that programs can use to better understand how certain filters will impact their program. Lastly, one member noted their support of organ offer filters, but that the project should be focusing on improving the organ discard rate.

HonorBridge | 09/28/2022

HonorBridge supports the use of mandatory offer filters. Usage of filters will drive efficiencies in the organ offer process and reduce the increasing kidney discard rate. The volume of kidney offers that are declined that could have been screened off based on a programs historical performance would be a significant step forward to getting to the right recipient for each organ donated. Transplant centers should have the flexibility to opt out of filters for certain candidates, such as pediatric patients.

Region 8 | 09/27/2022

Several members supported the use of offer filters and that offer filters should be mandatory. One member did not support the filters being mandatory and also suggested that there be filters for other organs. A member suggested to begin with default filters then move to mandatory filters if a center isn’t consistently using the default filters. The member suggested that if mandatory filters are implemented, there needs to be the capability to remove filters for specific patients. In support of mandatory offer filters the member also suggested that centers should annually review their filters and make appropriate changes. The member inquired if there will be allowance for an acceptance for hard to transplant patients, and the plan for filters on other organs. In support of mandatory filters a member suggested that a center's filters should be determined by evaluating past organ acceptance/decline data and evaluated/updated every two years. A member inquired as to the negative impact that offer filters could have. Another member asked to see offer filters for livers, especially with enhancements for candidate listings: Liver, having distance criteria for patients, DCD organs, etc. Several members explained that their centers initially had too aggressive of filters but were able to modify them to more accurately reflect their acceptance practices. Regarding data, a member commented that OPTN data on filtered offers should be updated – a member should be able to request date ranges, and the OPTN should provide different formats (i.e. a tilt table). The member also wants to be able to view filtered offers for patients. A member supported increased filter use, and also inquired: (1) What would happen to a center that is already using offers filters, (2) Would the recommended filters be implemented over what a center may already be using? The member explained that at her center, they do not implement the filters model recommendations because the data was based on acceptance practices before the 2021 distribution changes. If filters become mandatory, her cent would support implementing with a focus on one item at a time like distance or CIT so we can understand the data we receive on why the offer was filtered out. The member suggested to make the data reports for offers filters user friendly so that the member can understand what changes occurred. A member commented that in order to ensure filters are being utilized appropriately, the filter report needs to work. The member explained that the report function within UNET is not functional.

Association of Organ Procurement Organizations | 09/27/2022

Please see the attached comment from the Association of Organ Procurement Organizations

Attachment

New England Donor Services | 09/27/2022

The process of placing medically complex kidneys could be greatly improved through the use of mandatory offer filters. The waitlist acceptance criteria for kidney candidates and the donor match run process only exclude candidates from appearing on a match run based on a very limited set of candidate and donor parameters. Organ offer filters enable kidney transplant programs to create additional multifactorial exclusion parameters to reduce the number of kidney offers from donors with factors they would not accept. The use of these filters accelerates the allocation process by reducing unnecessary offers to transplant programs unwilling to accept such kidneys so OPOs can allocate more quickly and efficiently to those centers more likely to accept difficult to place kidneys. This also reduces cold ischemic time enabling placement to those centers sooner. The use of filters should be required for all kidney programs, based on historic acceptance practices and eventually implemented for all organ types to increase efficiency and maximize the placement of organs.

Region 7 | 09/27/2022

Members of the region were supportive of the use of organ offer filters, but many voice opposition to mandatory usage without the ability for a program to evaluate their practices and make changes to the filters. The general consensus of an opt out system or voluntary usage was best for programs. Several in attendance noted strong support for allowing patient specific filters, and for the transplant programs to have autonomy to turn off filters for certain patient populations like highly sensitized or pediatric candidates. Members also suggested that their needs to be more education for programs to learn how to use offer filters and best utilize them for their specific program. In addition, there should be more education about the currently available Offer Explorer Tool, the tool addresses many of the concerns regarding the transparency around the filter system. One member noted that many programs are confusing the OPTN’s Minimum Acceptance Criteria tool with offer filters. The two need to work in conjunction and more education is needed for programs in regards to the two. There should also be separate filters for DCD donors. In regards to patient specific filters, there should be a check box in the candidate’s listing to note if the program’s default filters should apply for a given patient. If the check box is not marked then the program can set the appropriate filters for that candidate. Lastly, it was noted that if the offer filters are made mandatory programs should be allowed to review their filters periodically. In addition to education about the use of offer filters the OPTN should offer education on the proper use of offer filters if a program is noted for declining a large number of offers. There may be a filter available for those offers that the program could apply in order to improve allocation efficiency.

American Society of Transplantation | 09/27/2022

The American Society of Transplantation (AST) generally supports the approaches outlined in this concept paper, ideally using “Option 1 - Default Offer Filters.” The AST offers the following comments for consideration as this work continues: Filters have the potential to increase kidney placement efficiency and utilization. Programs need the ability to modify their filters, thus, the default option is the preferred model. The challenge will be who makes these decisions, who enacts them in UNet, and how to adjust for each patient. It will be critical that the OPTN creates a process and tools that are easy to implement and allow for dynamic, smooth changes to filters in the future. Certain hard to match candidates should never be subjected to having offers filtered. It will be important that the filters include mechanisms that allow programs to make adjustments easily so hard to match candidates receive appropriate offers. Regarding the evaluation of acceptance data, members provided varied responses ranging from every six months to biannually. Program acceptance behavior evaluation frequency should also consider program size/annual number of transplants. All filters should be utilized and monitored. If a program continues to decline particular organ offers based on their settings, then the program should be notified that the setting will be adjusted unless they take a different action. Based on data in the concept paper, there are still a significant number of programs that haven’t accessed or utilized the offer filter data or input filters for their programs which indicates something at the center level need to be done. Please consider sending programs individual evaluations as a start. The AST recommends that the OPTN implement changes in this concept paper first, before approving any changes to provisional yes policy. To improve efficiency as much as possible, objective "internal refusal reasons" envisioned to comprise the Tier III decision making criteria in the concept paper, “Redefining Provisional Yes and the Approach to Organ Offers,” should be incorporated into the organ specific offer filter criteria as well. If or when provisional yes policy proposal is implemented, Tier III decision making behavior could inform future changes to offer filters. The AST recommends that programs are transparent with patients about their usage of offer filters.

Attachment

OPTN Histocompatibility Committee | 09/27/2022

The Histocompatibility Committee thanks the OPTN Operations and Safety Committee for their concept paper. The Vice Chair suggested allowing programs to opt out of filters for given patients. He noted matching patients with the same CPRA does not result in the same level of difficulty. Members stated there should be additional candidate opt out options based on candidate sensitization level, as opposed to a default level. A member suggested automatically removing filters for those with a CPRA of 98% or higher. A member argued there should be flexibility despite CPRA level because it varies based on region or locality. There were no further comments from the committee.

American Society of Transplant Surgeons | 09/27/2022

The American Society of Transplant Surgeons (ASTS) thanks the OPTN Operations and Safety Committee for their work on kidney offer filters. ASTS supports optimization of kidney offer filters in order to improve efficiency in organ allocation and increase organ utilization. ASTS supports the initial implementation of default offer filters (option 1) that will automatically enable identified filters for all centers unless centers specifically opt-out. Once the default, non-mandatory filters are initially implemented (perhaps 6 months), filters could then become mandatory based on recently collected data. Mandatory filters will improve organ utilization, but the implementation should not prevent centers from changing their acceptance patterns over time. Without the ability to change acceptance patterns, centers will be limited to selecting donors based on past behavior. Programs may be disadvantaged based on size or geography (travel distance and CIT). By implementing filters that are less restrictive than the model identified filters (option 3), centers will have room to alter behavior. When mandatory filters are implemented, ASTS recommends a straightforward pathway for programs to request filter liberalization (rather than complete removal). Circumstances for liberalizing a center’s filter might include low volume centers, changes in center staff (transplant physicians/surgeons), or a significant change in a center’s SRTR outcome data. If filter liberalization is requested by a center but the center continues to decline organs after a 6-month period, ASTS agrees that the mandatory filter should reset automatically. ASTS also supports the proposed evidence thresholds but suggests changing the number of donors filtered from 20 to 100 donors. In the model data provided, this threshold balances a significant change in the number of non-accepted offers bypassed, with a small impact on accepted offers that are bypassed. Additionally, the mandatory filters should not apply to certain hard to match candidates (cPRA >97%, 0 antigen mismatch). ASTS proposes that acceptance data for adjusting model identified offer filters should be re-evaluated for transplant programs every 6 months when new SRTR data is published.

Attachment

Region 11 | 09/26/2022

An attendee commented that more than offer filters has to be done to address the discard rate. Several attendees that use offer filters spoke in support of their effectiveness. Another attendee stated that improvements need to be made at the organ offer level to place kidneys as quickly as possible to programs that will use them. Another attendee commented that centers must retain flexibility and autonomy in decision-making and does not support offer filters being mandatory. Several attendees recommended that more education (including program to program mentoring), data, and IT enhancements are needed to increase usage. Another attendee supports making it mandatory for programs to use offer filters, but that they should be able to select their filters. One attendee questioned whether or not offer filters should be used for pediatric programs and if so, the data would need to consider that sometimes pediatric candidates receive offers that are not ultimately accepted for a pediatric candidate.

Gift of Life Donor Program (PADV) | 09/26/2022

Gift of Life Donor Program (PADV) thanks the Operations and Safety Committee for their work on this proposal and the opportunity to provide feedback. Gift of Life believes that the OPTN must promote increased filter use and supports making filters mandatory for all transplant programs. Offer filters have been proven as outlined in the proposal to reduce unwanted organ offers and increase allocation efficiency. However, only 73 centers have turned on filters, this alone is evidence that if filters continue to be voluntary, they will continue to not be used effectively. For organs at high risk of discard, offer filters enable the OPO to connect with a center who is more likely to accept the organ sooner, directly reducing cold ischemic time upon arrival to the accepting center. Offer filters are also likely to reduce the need for expedited placement by OPOs, as time historically spent working with programs who ultimately decline the offer will be reduced. OPOs with a high density of transplant centers such as Regions 1 or 2 often work with 60 or more transplant centers in their first 250 nautical mile radius during every allocation. Mandating the use of offer filters is an essential step to decrease the amount of offers necessary to place an organ, decrease the time from initial offer to kidney acceptance and ultimately decrease the national kidney discard rate. While the initial rollout of filters has been successful, the next phase of offer filters must be more dynamic. First, filters should be able to be applied both before a notification is sent and after a provisional yes has been entered when there is new information such as cross-clamp time or biopsy. Because OPOs send organ notifications prior to recovery to adequately identify and prepare suitable candidates for kidney acceptance, efficiency post-recovery is lost when centers that entered provisional yes responses must be contacted despite the offer no longer meeting their acceptance criteria. Second, filters must be fully customizable by each program and multi-factorial, e.g., donor age and distance vs. recipient age, or cold ischemic time and DCD vs. candidate wait time, in addition to current filters. This customization will allow the filters to be both program & patient driven, meaning centers can set absolute program limits for acceptance, but may also identify patients suitable for marginal offers for whom the filters can be made less restrictive. Gift of Life supports proposed option 1, in which default filters would be initially applied based on past acceptance criteria, however, would allow the center to adjust or remove the filters. This will drastically increase allocation efficiency without limiting opportunity for a center to receive more marginal offers if they choose to become more aggressive in the future. This would allow each program to focus on offers that they would realistically accept, rather than expending time and resources evaluating offers they would never realistically consider. However, it does not limit or make it difficult for a program to increase their acceptance criteria should they wish to consider more marginal offers. This option also allows for filters to be removed if a smaller center felt they would be disadvantaged using historical data. Gift of Life suggests the initial implementation of model identified filters for all centers with a threshold of less than 2% of accepted organs that would have been bypassed by the filter. This could be followed by individual program data provided every 6 months with updated filter recommendations based on rolling 2-year acceptance behavior. These suggested filters would not be mandatory or automatically applied. Gift of Life is concerned that proposed option 2, which does not allow the center to adjust their model identified filters, makes it too difficult for a center to change their acceptance behaviors and does not provide enough options for customization. While certain types of candidates (high CPRA, 0-ABDR mismatch, etc.) could be always excluded from filters, as stated in the proposal, this again may ultimately result in unwanted offers to patients who are likely to be near the top of the list and thus impede allocation efficiency. Gift of Life believes that customizable, dynamic filters are the best way to reduce unwanted offers while ensuring that offers that may be considered are not missed. Both options proposed place the onus on transplant programs to adjust their filters and ‘opt-in’ to receive marginal offers before those offers are sent, rather than on the OPO to weed through centers that have never considered such an offer. Mandating the use of filters will help ensure that the right organs get to the right centers with less cold ischemic time, leading to higher kidney utilization and better patient outcomes.

Gift of Life Michigan | 09/26/2022

Please see attached pdf for full comment

Attachment

OPTN Transplant Coordinators Committee | 09/23/2022

The OPTN Transplant Coordinators Committee thanks the Operations and Safety Committee for their work and for the opportunity to comment on this concept paper. One member remarked that there is considerable overlap between offer filters, acceptance criteria, and minimum acceptance criteria for kidney. The member recommended a more streamlined approach between the different filtering tools, so that a program can avoid discrepancies between systems. The member noted that the current organization is confusing to navigate, particularly when filtering based on candidate and donor information. A member expressed concern about bypassing offers based on transplant program historical acceptance behavior, noting that acceptance behavior can vary between surgeons at the same institution. The member noted that more aggressive surgeons may not be okay with being screened from offers they would consider accepting for their patients. The member recommended that offer filters can be changed and applied differently based on candidate age, noting that their program is much more conservative when evaluating offers for their pediatric patients than for their adult patients. Several members expressed support for a default model, noting that transplant program behavior can change dramatically based on staffing changes. One member emphasized the importance of flexibility for programs in changing their behaviors.

Laura Hulse | 09/22/2022

Presented during this summer 2022 public comment cycle is the OPTN Ethics Committee white paper related to the Committee’s analysis of the ethical principles in support of transparency to inform patient selection of a transplant center. The OPTN Ethics Committee has argued that to preserve patient autonomy and support shared decision-making, there is a need for transplant centers to provide additional information to patients which may impact the individual patient’s access to transplantation, patient selection criteria. During this same summer 2022 public comment cycle, the OPTN Operations and Safety Committee has presented a concept paper for comment, Optimizing Usage of Kidney Offer Filters. While these papers come from separate OPTN committees, I feel there is overlap related to the ethical principles of transparency. The OPTN Operations and Safety Committee present a persuasive argument that the use of offer filters is one of many strategies for increasing the efficiency of organ placement, particularly for kidney transplantation. As a network of independent, yet interdependent organization of transplant hospitals and organ procurement organizations, efforts to improve efficiency of organ placement are necessary to ensure optimization of the system. Concern is raised with the kidney offer filter proposal by the OPTN Operations and Safety Committee related to potentially mandatory use of organ offer filters. Mandatory implementation of organ offer filters at a transplant program, implemented and controlled not by the transplant program but rather by the OPTN, presents a similar challenge to autonomy and shared decision-making. Should the OPTN implement different organ offer filters at different kidney transplant programs based on historic data, would this further exacerbate inequities in access to transplantation at the patient level? How would patients be made aware of the differences in organ offers they would have access to due to OPTN implementing filters? Will the OPTN make public each center’s offer filter thresholds so transplant candidates can better understand differences between programs? How would a center which transplants both pediatric and adult candidates be affected? We acknowledgement that our transplantation system presents certain communities with disadvantages in access to deceased donor kidney transplant based on geographical location, insurance payer reimbursement, etc., but broadly removing the autonomy of a transplant program to filter organ offers for the individual candidate further removes patient autonomy, prevents shared decision-making with the patient, and potentially trust in the transplantation community.

Region 1 | 09/21/2022

An attendee commented filters are easy to use and extremely helpful. We have seen a 70% decline in offers during which time our transplant case volume has increased. Another attendee commented the ability to apply candidate specific offer filters would be necessary for programs that attempt to make use of organs otherwise declined. I cannot understand why they have not been more widely adopted. Mandatory filters are not necessary and should not be supported. Another attendee stated the need to encourage, perhaps require, filter use, but be careful not to be too restrictive towards programs trying to change their acceptance patterns. One attendee pointed out the offer filters explorer is helpful, but hard to find in the data service portal and that easier access may increase usage. The comment was made that it would be helpful to be able to redefine the period of time the offer filters are analyzed as programs and surgical teams change. Another attendee commented there has been a lot of unnecessary criticism or accusations of complexity to the filters. Attendees agree that the filters are underutilized. One attendee pointed out that making it mandatory will make it harder to change practices. Another attendee mentioned that you need filters, but they should be flexible and you should have an option to change many different facets of an organ: KDPI, cold time, distance, etc. An OPO representative commented that the filters are important and recommend having a default system where it’s mandatory, but the programs can go in and change the parameters. A few attendees suggested there should be a tutorial about how to use the filters. Another attendee suggested we switch to mandatory filters for post-cross clamp offers only.

Region 3 | 09/20/2022

Several attendees supported default filters that would require transplant centers to take an action to turn them. They were not in favor of mandatory filters due to the variability in changes that effect acceptance practices. Another attendee commented that improving the granularity of filters is a welcomed advancement. One attendee commented that it would be helpful if a center could run a report of offers that were filtered on a monthly basis and have the ability to see what was filtered out. One attendee commented that unlike other policy making processes this is an opportunity and call to action for the community to get engaged using offer filters and encouraged transplant colleagues to bring this to their programs to explore and utilize. Others agreed and encouraged transplant centers to go on line and explore the filters to see how the tool would work for them. One attendee commented that if offer filters and wait list management were used appropriately, the Tier system would not be necessary. One attendee whose center is using offer filters commented that it helped offload call centers work. Another attendee asked if the acceptance criteria centers submit for the Organ Center could be used for all offers rather than just national offers. They added that the filter page on UNet is still DSA based and asked when it would be updated to nautical miles. Several attendees supported mandatory filters commenting that it would streamline the process, increase utilization and reduce cold ischemic time. One attendee commented that the appropriate threshold to apply the filters is 100, the center should be able to remove filters and the acceptance data should be re-evaluated every 6 months.

Organ Procurement Organization Committee | 09/20/2022

The OPTN Organ Procurement Organization Committee thanks the Operations and Safety Committee for their work and for the opportunity to comment on this concept. Several members expressed support for the mandatory filters based on center behavior and data evidence, citing system inefficiency and the importance of transplant program accountability in filtering out offers that the programs will not accept. One member expressed support for the inclusion of cold ischemic time as a filter, particularly in the context of distance. One member pointed out that the main issue with the offer filters seems to be getting programs over the hump of setting the filters up, and remarked that mandatory filters is the only way to make the filters work. The member noted that the lack of offer filter use conflicts with transplant program complaints about the volume of offers, and that making offer filters mandatory could help solve this problem. One member expressed support for mandatory offer filters, adding that OPOs want to place the organ with the most appropriate recipient as quickly as possible, and that mandatory filters will encourage this by helping programs manage their list. One member expressed support for default filters, and suggested that programs may not have had the time to evaluate and implement offer filters yet. The default filters would allow the programs to look into the filters and encourage utilization. One member pointed out that, if the program can turn off the filters, the filters are not mandatory. Members agreed that programs need to be required to use filters to some degree. One member recommended a policy that requires programs to try offer filters for some set period of time, to see how the filters work and affect their work flows. A member noted that programs could maybe appeal certain filters under a mandatory system, but that programs shouldn’t be allowed to opt out of utilizing the filters entirely. One member noted that, with the default option, programs could end up reverting to using only ineffective filters. A member recommended reapplying offer filters more often than once a year. The member noted that this could be more difficult for smaller programs, but that all programs need to be using offer filters. Another member noted that basing mandatory offer filters on the last two years of data may be unfair, as programs were more conservative in the COVID-19 era than they may have been otherwise. One member expressed support for a mechanism of flexibility, to allow programs to demonstrate change in their acceptance practices. One member suggested including late declines in offer filters, so that programs could indicate that they would be willing to accept and recover an organ themselves some set amount of time before planned organ recovery. The member explained that operating room and family restrictions can lead to post-recovery complications, which offer filters could potentially help avoid.

Region 2 | 09/13/2022

Members in the region overall are in favor of organ offer filters, but are split over whether offer filters should be mandatory. One member noted their program has had a good experience with organ offer filters and screening out futile offers. They currently have similar rates of transplant and the filters have not hindered access but has increased efficiency. In support of mandatory filters, one member stated it is a real opportunity to increase efficiency of allocation based upon a center’s past history of organ utilization and reduce the organ discard rate. Additionally, programs should see this as stewardship for a valuable and limited resource. One member noted that if the filters are made mandatory programs should have the ability to review data and the filters on a quarterly basis. Another member stated small programs are generally not in favor of removing power from the surgeons, but this concept could be beneficial for the system if offer filters are made mandatory. They suggested adding donor/recipient age and size matching to current filters and consider offering KDPI/EPTS parity filters. Other members support the usage of offer filters, but are weary of making them mandatory. One member noted that offer filters are great step forward; however, mandatory may be one step too far. It may be more helpful to send out a notice with analysis that prompts the program “in the past you have not accepted this organ, if you implement this filter then you will stop receiving these offers. Would you like to apply filter?” Also the project should focus on hard to match candidates in the filters by highlighting those patients to remove offer filters in order to increase the chances of an organ offer. Another member commented that caution should be used in making offer filters mandatory. Programs with small numbers and new programs will be disadvantaged statistically. There should be a mechanism and/or cutoff that would allow these smaller centers to opt out and prevent small programs from missing out. Additionally, parameters should be reassessed as centers wanting to become more aggressive will not be allowed the opportunity. This could also impair patient access and as such would need to be addressed from a transparency point of view. Another member voiced concern that this is a program driven concept but it is only as good as the next patient listed. Programs should have the autonomy to suspend mandatory filters for certain patients who are using a more aggressive approach to getting transplanted. This could help reduce discards by giving those who are willing to accept marginal offers the ability to do so. The concept needs to be more patient driven than program driven. Lastly, a member noted hesitation that attempts at increasing the usage of existing organ filters will act as a remedy to program "burnout" as a result of the large increase in organ offers.

Region 9 | 09/12/2022

Two attendees commented that the filters are functioning on data that is greater than a year old and should be more up to date so that programs can be agile in decision making. Another attendee commented that the filters are not sophisticated enough for their use. They added that if the filters were more specific (distance, age, DCD status, etc.), they would be more useful. Several attendees were in favor of using offer filters but did not support making them mandatory. Several attendees commented that member education will be key in getting more programs to move forward with using filters. Several attendees support the use of filters which are adjusted by individual transplant programs. They added that periodic data analysis and feedback should be given to programs to aid in ongoing filter adjustment over time. UNOS' analysis should be presented to the centers and then the centers should be allowed to set their own filters.

Christine Warywoski | 09/11/2022

I recently read an article in The Boston Globe about how some hospitals routinely reject organs that are 70 years old and up. I was given a 65 year old kidney from a deceased donor. My kidney is now 90 years old. I have had it for almost 24 years and it's still doing well. Older kidneys can do well in the right recipient. In was 48 when I got my kidney and am now 72. If I need another I would certainly accept a kidney from an older donor.

Region 5 | 09/08/2022

A member suggested that the offers be multifactorial and utilize a sophisticated algorithm. A member thought that the criteria for filtering, although helpful, is too broad at this stage. She suggested to make the filters specific enough to filter out criteria according to center practice. Specifically, it would be helpful to be able to look at multiple filters together – such as, cold ischemic time, age, and travel time; or history and creatinine. A member suggested that the filters be mandatory and that less stringent filters should be applied to local offers so that transplant centers have opportunities to change its practice. Another member explained that his institution successfully uses the filters and is able to make them specific enough for their use. He said the filters are a benefit for them and have made a positive impact. A member suggested being able to utilize filters based on a candidates age – where there are separate filters for pediatric and adult populations. Another member supported the default filters based on a transplant centers history, but suggested being able to modify the filters based on candidates. The member thought it would be onerous to have to ask for change to the default filters. A member explained that transplant centers who are using the filters report positive success in streamlining offers to be the ones they will actually consider. These should be mandatory. Several members supported mandatory filters for distances beyond a certain number of miles.

Glyn Morgan | 09/07/2022

There is no reason to modify the organ offers filter tool at this time. We must encourage widespread adoption without invoking mandatory requirements. We applied filters the very first day they were activated and have seen a 60% reduction in offers - all of which would have been declined by our center. During the same time we have performed more deceased donor kidney transplants with no increase in DGF rates. Most importantly our team is better rested, less stressed and can concentrate on the suitable offers made to our list. Programs should also look at their Kidney Acceptance Criteria and the OPTN should ensure that offers made reflect the selected criteria for each program. Lastly, the candidate registration forms must be accurate and truly reflect the wishes and criteria chosen (serology, etc.) by the patient and program. We already have the necessary tools at our disposal - we need to use them. This is not difficult - it simply takes a bit of time and effort to get things right the first time. There is no need to revise the offer filters tool at this time - just use it! I would suggest that programs be asked to apply filters of their choosing within 60 days. Selecting even a single filter can result in the elimination of hundreds of unwanted offers.

Kidney Transplantation Committee | 08/31/2022

The OPTN Kidney Transplantation Committee thanks the Operations and Safety Committee for their work and for the opportunity to comment on this proposal. Several members shared that their program utilizes the offer filters tool, and that the tool has been highly effective and has had a positive impact on their program. Members expressed support for some kind of mandatory filters, with the caveat that programs need to be able to change the filters and change their behavior, and filters themselves shouldn’t be based on historical data alone. Some members emphasized that programs should have the ultimate right to change their filters, and that making the offer filters mandatory could be too aggressive, particularly for smaller programs. A member pointed out that the data utilized in the offer filters may not be an accurate representation of center behavior, or capture why the center has turned down certain offers. For example there could be issues with biopsy, anatomy, logistics, or even just that the organ isn’t a good match for that recipient. A member recommended that navigational routes and logistics be considered as a potential filter, as in many cases, an organ cannot actually arrive to a program within a reasonable timeframe, particularly when considering air travel. Other members encouraged increased education for both transplant programs and patients on offer filters. If a program is using filters or filters become mandatory, this should be communicated with patients, so that they are aware that certain types of kidneys will not be offered to them due to filtering. Additionally, education should be developed for transplant programs on how offer filters impact odds ratios for organ acceptance as many programs are likely under-informed when it comes to how new acceptance rates are viewed and tabulated.

Region 4 | 08/26/2022

Comments: Region 4 was generally supportive of offer filters. One attendee whose program is using offer filters commented that it works really well and decreased offers by approximately half. They added that they only use filters that would apply to offers they had not accepted in two years. Another attendee whose program was using filters commented that they used two of the four “recommended” filters and created their own filters based on absolute rule outs which decreased the number of offers they receive by half. An attendee whose program uses offer filters commented that it did not decrease their transplant volume and added that we will have more data over time as more centers use the filters. Several attendees did not support making any filters mandatory adding that programs should be able to adjust the filters based on changes in organ offer acceptance practices. One attendee commented that they support default filters but not mandatory filters. An attendee commented that the current filters don't work and that they still receive offers outside their program criteria. They added that mandating filters does not work for pediatric patients, as criteria for 1-7 year old patients is significantly different than those 15-17 years of age. Several attendees supported use of filters to eliminate organ discards and inefficient allocation. One attendee supported mandatory use with frequent assessments for center specific adjustments as needed. Another attendee commented that when filters expand to hearts, centers will need the ability to make changes based on technology changes. An attendee supported anything that can be done to encourage greater use and application of offer filters through incentives (or disincentives if not used) to accelerate the offer process. They went on to comment that the system must deal earnestly with centers that never accept categories of kidneys yet do not apply filters. One patient representative commented that the patient community strongly supports mandatory filters. Another attendee commented that filters will help centers manage capacity issues, adding that they should be able to re-evaluate every 6 months and should be able to exempt highly sensitized patients and receive statistics on the change effect. Several attendees did not support applying offer filters to pediatric candidates.

LifeGift | 08/11/2022

Totally support. We must drive increased use of existing filters to help manage the capacity issues at tx centers and help find ways to reduce the complexity of the offer process. This is not a new idea at all but rather a more assertive step to actually implement. Regarding the approach of based on experience or a mandatory assignment of criteria, it will be important for centers to be able to opt out selected highly sensitized candidates. Suggest also trying this for a 6 month period on some pilot centers and then looking at impact before implementing broadly. Thank you

Kidney Donor Conversations | 08/04/2022

Support initiatives to improve efficiencies and decrease wait time for recipients.