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Bureaucracy Failing Patients

Allocation Out of Sequence: Balancing Equity and Utility To Save Lives

The Organ Procurement and Transplantation Network (OPTN), at the direction of the Health Resources and Services Administration (HRSA), is laser focused on the issue of Allocation Out of Sequence (AOOS).

This nuanced balance of equity versus utility is being driven by a dramatic increase in the number of organs available through DCD donors, who tend to be older and sicker. As medicine has advanced we are now procuring and placing organs that would have been untenable decades ago.

We need policies that keep pace with the reality of our system.

The OPTN creates, implements, and monitors organ allocation policy. They are responsible for setting the rules around how organs should be offered for transplant. The OPTN is purporting to ensure fairness, transparency, and optimal use of organs as they provide oversight around AOOS, but we must hold them accountable to assure good policy.

Why Are Organs Placed Out of Sequence?

In 2024 12,000 potentially life-saving organs were discarded in the United States. OPOs made more than 26 million attempts to place these rare gifts with transplant centers before they are ultimately discarded as medical waste. This is why OPOs refer to AOOS as a Rescue Pathway. They work diligently to assure the utility of donated gifts.

While it may seem logical and equitable to always give the next available organ to the person highest on the transplant list, it is not always what is best for patients. Organs from older and sicker donors, including Kidneys with a high KDPI, are not a good fit for patients at the “top of the list”, because they are also very ill. Healthier patients, who are further down the list, can have better survival rates with less-optimal organs.  According to research, “With appropriate recipient selection, high-KDPI kidneys can improve patient quality of life, reduce wait times, and lower healthcare costs.”

The balance between equity and utility is happening every day at transplant centers around the country.  Listen to SID&T Advisor Dr. Matt Cooper as he discusses how to balance equity and utility.

Transplant surgeons like Dr. Cooper, who is on the phone with OPO coordinators working to find homes for precious gifts, know that less-than-optimal organs can and do save lives every day. However, these organs must go to the centers that have the capacity and willingness to use them, and to patients who will most benefit from that particular organ.

Not all transplant centers are alike.

There is evidence that transplant center behavior is driven by measures around the one-year survival rate of patients and the Scientific Registry of Transplant Recipients (SRTR) clearly notes the wide range of performance among centers. It is well known in the field that certain centers and surgeons will accept hard-to-place organs. Very often a center willing to use an organ is across the street from a center that has no interest.

In the field, the goal is to find a home for an organ before the clock runs out and the gift is no longer viable. Assuring the utility of a donated organ can, and should, outweigh the perceived equity of the next in line.

Policy Must Create Alignment

To save more lives and decrease non-utilization, the system needs alignment between the goals of the OPO and the transplant center. The CMS Final Rule measures OPOs on the number of organs transplanted, which the OPO can not fully control. Transplant programs are measured by one-year survival rates, which create a disincentive to accept organs that are not pristine.

Increased transparency and communication around best practices is already happening between OPO and transplant center leaders at conferences across the country as they work toward rebalancing the system in the wake of dramatic increases in DCD donors.