Kidney allocation changes expected by end of 2014

Cross-posted from Al Roth’s Market Design blog
The board approved substantial amendments to OPTN policy for deceased donor kidney allocation. Implementation of the policy is expected to occur at the end of 2014.
Features of the policy include the following:
  • prioritization of kidneys with longest estimated function to a limited number of candidates expected to benefit the longest
  • wider geographic allocation of kidneys with shorter potential function, to increase utilization for candidates facing a significant mortality risk remaining on dialysis long-term
  • definition of waiting time expanded to include time a patient spent on dialysis prior to waiting list registration
  • a sliding scale of priority for candidates with high PRA, as well as matching of blood subtype A2 and A2B offers for candidates with blood type B, and
  • elimination of the kidney payback system and existing kidney allocation variances.

– See more at:                                                                             http://transplantpro.org/kidney-allocation-changes approved/#sthash.lbHqfgWL.dpuf

Al Roth – Nobel Prize Winner!

Congrats to our blogger, Al Roth, for his Nobel Prize in economics (alongside Lloyd S. Shapley of UCLA)!  Al built on Shapley’s theories about the best ways to match “agents” in markets — for example, students matched with schools or organ donors with patients needing organs — and conducted experiments to further illuminate Shapley’s work.  Al presented a really fascinating paper (with his colleague Judd Kessler) at one of last year’s Harvard Health Law Policy workshops on organ allocation policy and the decision to donate, and you can find lots more about his interesting work over at his Market Design blog.

Congrats again, Al! (Probably the best 4AM wake up call a person could get!)

Incentives for Blood Donation

Al Roth has an interesting post up today at his Market Design blog referencing some data on the crowding out effect, i.e., the idea that if you pay people for something that they are currently donating, altruists will be “crowded out” and you’ll end up with less of the thing that you need.  It turns out that the data just don’t support that theory.  Check it out.

Commentary from OPTN/UNOS Kidney Transplantation Committee Chair, John Friedewald

Related to Nikola’s post below on the proposed revisions to the deceased donor kidney allocation policy, Al Roth has posted some interesting commentary from OPTN/UNOS Kidney Transplantation Committee Chair John Friedewald (in response to a query on a list serve):

“The current proposal for kidney allocation from the UNOS kidney committee is what it is not because it was the first thing we thought of, and “wow, it’s perfect” but rather it is the product of 8 years of trial and error, consensus building, and compromise.  To state that EOFI takes into account both equity and efficiency would seem to suggest that the current UNOS proposal does not.  How could this be?  We have tried over 50 different methods of allocation and simulated them (which has not happened yet with EOFI).  And with each simulation, we view the results and how the system affects all sorts of different groups (NOT just age, but blood type, ethnic groups, sensitized patients, the effects on organ shipping, the effects on real efficiency in the system (the actual logistics).  And we have seen that some methods of allocation can generate massive utility (or efficiency in your terminology).  We can get thousands of extra life years out of the current supply of organs.  But in each instance, we have made concessions in the name of equity.  The current proposal does not increase or decrease organs to any age group by more than 5% (compared to current).   This has been our compromise on equity.  What we see in utility/efficiency is an extra 8000+ years lived each year with the current supply of organs.  So the current policy has done a tremendous amount to balance equity and utility.  And we have left thousands of life years lived on the table in the name of equity.  Now you may argue that we have not done enough in that regard, but rest assured, we have given equity hundreds of hours of consideration.

TODAY – Deceased Organ Donation and Allocation: 3 Experiments in Market Design

Sorry for the late notice, but we just learned that Al Roth will be giving a talk with this title TODAY @ 3:30 at Stanford.  More info here.

Al has also pointed us to two relevant posts over at his Market Design blog:

Allocating deceased donor kidneys for transplant: problems, some proposed changes, and how can we get more donors?

Two recent NY Times stories discuss the allocation of deceased donor kidneys:

A few different things are intertwined here: the long waiting lists, the congested process of offering kidneys and having them accepted or rejected and offered to the next person on the list, and the ordering of the list, which in turn might influence how often people need a second transplant, which comes back to how long the waiting lists are…There are lots of interesting and important questions about how to most efficiently allocate the scarce supply (see e.g. Zenios et al.)But organ allocation has an unusual aspect: how organs are allocated may also influence the supply, by changing donation behavior. [And this is the topic of Al’s talk today.]

Older kidneys work fine (thank you for asking:)

Older Kidneys Work Fine for Transplants“Using data from more than 50,000 living donor transplants from 1998 through 2003, researchers at the University of British Columbia concluded that the age of the donor made no difference to the eventual success of the transplant — except for recipients ages 18 to 39, who were more likely to succeed with a donor their own age. Patients in this group accounted for about a quarter of all the patients studied. The scientists also analyzed lists of people waiting for a kidney from a deceased donor and found that the probability of becoming ineligible for donation within three years was high, varying from 21 percent to 66 percent, depending on age, blood group and severity of disease. Waiting can be fatal, the authors contend, and an offer of a kidney should not be rejected simply because of the donor’s age.”

The Supply of American Doctors

Following up on his post on Australia, Al Roth notes that American medicine is a market with tightly restricted entry, at all levels. Proposed legislation offers a glimpse: Bill Would Create More Medical-Residency Slots, Potentially Easing Physician Shortage

Legislation introduced in Congress on Monday would expand the number of Medicare-sponsored training slots for new doctors by 15,000, a step that two medical-education groups said would go a long way toward easing a projected shortage of physicians. The bill, the Physician Shortage Reduction and Graduate Medical Education Accountability and Transparency Act (HR 6352), is sponsored by Rep. Aaron Schock, an Illinois Republican, and Rep. Allyson Schwartz, a Pennsylvania Democrat. Medical schools have been expanding their enrollments and new schools have been opening up as concerns have grown about a shortage that could reach more than 90,000 physicians by 2020, according to the Association of American Medical Colleges. Those worries have intensified with passage of the Affordable Care Act, which will greatly increase the number of people seeking medical care by providing insurance coverage to 32 million more people. But while more students are making their way through the medical-school pipeline, they’re likely to run into bottlenecks because of a cap on the number of Medicare-supported residency training slots that Congress imposed in 1997.

[cross-posted on Market Design]

Market Design Flaw in Australia

Al Roth has come across a troubling phenomenon in Australia, where medical internships are in short supply.

Medical students languish in a critical condition

The Australian Medical Students’ Association estimates almost 500 students will miss out on an internship next year because of insufficient places. Under the internship system students must work for a year under supervision in a hospital before they can work as doctors. … Australian Medical Association president Steve Hambleton points to the curious situation where the nation has a shortage of doctors, yet there are too few internships.  … The placement system has fallen apart, he says, because the federal government regulates the number of students universities can enrol while its state counterparts oversee the provision of internships. 

[cross-posted on Market Design]

 

Al Roth on the Circumcision Debate

[posted on behalf of Al Roth]

Al will be cross-posting here from his Market Design blog, and he’s let us know that he plans to follow-up soon on the circumcision debate around the world.  For a preview of what’s to come, check out his related posts from earlier this summer: http://marketdesigner.blogspot.com/search?q=circumcision&max-results=20&by-date=true.