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We’ve got the best organ donation and transplant system in the world. Here’s how to make it even better.
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We’ve got the best organ donation and transplant system in the world.

Here’s how to make it even better.

One of the best parts of my job is being able to tell people that America has the highest-performing organ donation and transplant system in the world. We have more organ donors and more annual transplants and we save more lives through organ donation than any other country.
Brian Shepard, UNOS CEO

“We’re not content with the status quo.”

Brian Shepard, CEO

And we’re getting better all the time. Today, American surgeons perform 40 percent more transplants than they did eight years ago. And even in a pandemic year, the system successfully performed 500 more deceased donor transplants from January through July 2020 than it did in the first seven months of 2019. Many other countries, by contrast, had steep drop-offs in the number of transplants performed this year.

Organ transplantation works for people who have end-stage organ failure. In almost all cases, it works better for people with kidney, liver, and lung failure than any other treatment available. People come to the organ donation waiting list because they know an organ transplant is a gift of life. That means that as good as our system is, it needs to be even better to be able to serve the more than 100,000 people waiting for organs at any given time.

At UNOS, the non-profit network that leads and coordinates the nation’s system of transplant hospitals, organ procurement organizations, and thousands of volunteers from the donation and transplant community, we’re not content with the status quo. Our commitment to continuous improvement has driven seven consecutive years of increases in the number of transplants performed. We also know there’s no quick fix to further strengthen a mature system with decades of experience and an infrastructure that covers the entire nation. And because we have a full view of how every step of donation and transplant works, we know that what we need now is a comprehensive set of reforms.

Earlier this year, the Centers for Medicare and Medicaid Services proposed changing the metrics by which OPOS are assessed. The proposal is well-intentioned and addresses many issues identified by the donation and transplant community. But it relies on faulty data and has met strong opposition from major stakeholders in the professional community — including the American Society of Transplantation, Association of Organ Procurement Organizations, and a number of individual transplant programs and OPOs.

And with a narrow focus on OPO metrics, CMS’ proposal does not take a broad enough look at the systemic approach that is necessary to continue to increase the number of transplants.

Because we have a full view of how every step of donation and transplant works, we know that what we need now is a comprehensive set of reforms.

Instead, UNOS proposes a five-part package of reforms, influenced by many conversations with people in the field — from surgeons and hospital staff to OPOs and organ donor families to transplant recipients and those on the waitlist. Some of these steps are within UNOS’ authority as the Organ Procurement and Transplantation Network. Others must be led by federal agencies.

These reforms would build upon our success as one of the leading systems in the world and save even more lives than ever before.

First, we need to automate real-time donor referral. This is a step we could not have proposed just five years ago. But today, hospital electronic health records give us an opportunity to have comprehensive, timely data about all potential donors. We believe we can build on that momentum and take the responsibility for referring donor candidates off the already full plates of hospital staff, who in most cases have to enter referrals manually.

UNOS and others are working to standardize a referral system that can be used by all U.S. electronic medical records providers, because automating donor referral will not only allow OPOs to identify more donors whose organs can be more quickly matched with more patients. It will also enable us to establish better metrics for OPOs and transplant hospitals.

Holding OPOs and transplants hospitals accountable for their performance and helping them to improve and save more lives requires consistent, reliable and timely metrics.

To better measure OPO performance, CMS has proposed a new metric that relies on death certificate data collected by the Centers for Disease Control and Prevention. But the CDC itself has acknowledged death certificates are not consistently accurate. They also lack the level of clinical detail OPOs, surgeons and patients need to determine donor suitability. For example, a death certificate might not tell us if the potential donor died on a ventilator or whether they had a disease that could put the transplant patient at risk. When only about 1% of people die in a way that makes them medically eligible for organ donation, having detailed information is crucial.

Automated donor referrals, on the other hand, would provide an improved, independently-reported and timely data source for understanding donor potential. This hospital-reported, patient-level data could be used to calculate a clear metric that CMS could use to assess and improve OPOs.

We also need to improve the process of getting the right organ to the right patient at the right time.

Organs sometimes go unused because the unique medical circumstances of the donor limit the number of candidates who could benefit from the organ. We’re working on a number of innovative projects to increase OPOs’ ability to place as many organs as possible, such as:

Similarly, we need to remove disincentives to using older and more complex donors when appropriate. Not every transplant candidate needs organs with the same projected life span, and one key step toward increasing organ transplantation is to use organs from older donors, which can be a good choice for some transplant patients, especially those who are older themselves. Unfortunately, today those organs are often rejected by transplant hospitals because they are more complex to work with — and by patients, who may not understand the viability of older organs.

We believe eliminating evaluation and financial disincentives for using these organs will help boost the number of transplants and save more lives.

Finally, we need to enable OPOs to merge or share services to boost their ability to serve hospitals and patients. CMS’ proposed rule provides no detailed transition plan addressing infrastructure in the service area of a decertified OPO, which could lead to ongoing disruption in parts of the country. Replacement organizations would need to rebuild the relationships and public trust necessary to maximize local organ procurement and distribution. Regulations that expedite or incentivize voluntary mergers among OPOs could expand the reach of effective OPO leadership without creating the risk of gaps in the organ recovery network.

There are thousands of things that each OPO, each transplant hospital, each staffer, UNOS, and CMS can do to drive improvement, but we’re targeting the things that we think apply to the whole system and that no individual part can do on their own. Taken together, these reforms will increase the pool of donors and organs, lead to shorter wait times and better outcomes, and mean more people receive lifesaving transplants. I’m excited by the potential for change, because as proud as we at UNOS are of the success of the organ procurement and transplant system, we know it has to keep getting better.

To learn more about the improvements we’re proposing, read the overview:
5 ways to improve
5 arrows pointing up to represent increased transplants
To learn more about the improvements we’re proposing, read the overview:
5 ways to improve

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