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Suggested Citation:"Index." Institute of Medicine. 1999. Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rule. Washington, DC: The National Academies Press. doi: 10.17226/9628.
×

Index

A

Access to quality health care, 39, 40, 47

Access to transplantation

current system performance, 1, 11

determinants of, 6-7, 12, 39, 45, 47

Final Rule effects, 3, 27-28, 46

Final Rule goals, 2, 26

Medicaid as factor in, 45-46

OPTN responsibilities in improving, 26

patient's travel distance as factor in, 44-45

socioeconomic differences in, 39-40, 41

waiting time as measure of, 10

Accountability, 131, 132

African Americans

access to transplantation, 39, 40, 41, 42, 44

donation rate, 33

histocompatibility testing, 42

organ donation rates, 51-52, 53, 56

posttransplant survival rate, 42, 98

transplantation patterns, 11

waiting times, 40

Age of donors, 50, 51

graft survival risk, 93

Age of transplant patient

likelihood of transplantation and, 86

posttransplant survival rate, 98

pretransplantation mortality risk, 86

status 1 patient outcomes, 69, 86

status 2 patient outcomes, 72, 86

status 3 patient outcomes, 76, 86

Allocation

current concerns, 2, 36, 38

current system, 5, 34-37

Final Rule goals, 2, 24

patient status as criterion for, 36-37

policies, effects on donation rates, 52-53

policy development, 25-26

recommendations for criteria, 90

system evaluation, methodology for, 6

system evolution, 18-19

waiting time as criterion for, 10-11, 35, 87, 90

See also Organ allocation areas

Alternative local units, 32

Asian donors, 51

Assessment, medical

cost of, 124

current inadequacies in, 24, 36

determination of organ acceptability, 93

standardization, 26, 36

Suggested Citation:"Index." Institute of Medicine. 1999. Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rule. Washington, DC: The National Academies Press. doi: 10.17226/9628.
×

B

Belzer UW solution, 17

Biological constraints

data collection for evaluating, 94

retrieval and preservation of organs, 91

size of organ allocation areas, 94

Blood type

posttransplant survival rate and, 98

pretransplant mortality, 86

status 1 patient outcomes, 69, 86

status 2 patient outcomes, 72, 86

status 3 patient outcomes, 76, 86

transplantation rate and, 86

Bone marrow transplantation. See National Marrow Donor Program

C

Caucasian donors, 50

Cold ischemic time. See Ischemic time

Compliance, medication, 41

Computer simulation, 95-96

Confidentiality, 3, 28

CONSAD computer model, 96

Cost of transplantation

components, 123, 124, 130

data sources, 124

definitions, 123

determinants of, 13

effects of broader sharing, 123, 129-130

Final Rule effects, 3, 13-14, 27-28, 123, 127, 128, 129, 130

organ acquisition, 129-130

per transplant, 124

posttransplantation compliance, 41

severity of patient illness, 127-129

sources of variation, 124

D

Delayed graft function, 92

Demand for organ transplantation, 2, 17-18, 51

Donation rates, 2

correlates of, 51-52

current status, 50-51

demand and, 18, 51

determinants of, 12, 33, 49, 50, 56, 59

donor age, 50

educational interventions to increase, 53, 56

effects of allocation policies, 52-53

effects of broader sharing, 49, 50, 51, 52-53, 59

Final Rule effects, 3, 12, 27-28, 49

growth of, 18, 50, 51, 53

OPO performance evaluation, 58-59

potential, 50, 58

racial differences, 50-52, 53, 56

strategies to increase, 56-58, 59

E

Equity in allocation

current concerns, 2, 23

current system performance, 1

determinants of, 12

outcome variations by patient status, 68, 78, 86

socioeconomic differences in access, 39-40

F

Family of organ donor

decision making processes, 51

outreach strategies to increase organ donations, 56-57

Final Rule

concerns about, 3, 26-27

effects on access, 11-12, 39-40, 46

effects on cost, 13-14, 123, 127, 128, 129, 130

effects on donation rates, 12, 49

effects on patient survival rate, 12-13

effects on small transplant centers, 43-45, 46

effects on waiting times, 3, 27-28, 61

goals, 2-3, 23, 26

liver allocation policies, 25

major provisions, 24-25

mandated review, 3, 27-29

monitoring, 95

origins of, 23

Suggested Citation:"Index." Institute of Medicine. 1999. Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rule. Washington, DC: The National Academies Press. doi: 10.17226/9628.
×

policy development provisions, 25-26

procedural requirements, 25

recommendations for allocation, 6, 10

text, 25

Follow-up, posttransplant

medication compliance, 41

posttransplant survival rate and, 98

Funeral expenses, 58

G

Gender differences, 86

posttransplant survival rate, 98

Geographical area of transplantation

current concerns, 2, 24

current liver allocation policy, 25, 37

current system, 5

effect on donor behavior, 12, 50, 52-53

regional variation in waiting times, 62

size, 1

system evolution, 19, 22-23

See also Organ allocation areas

H

Health and Human Services, Department of, Final Rule, 2, 3, 23, 24 -25

information management role, recommendations for, 15, 135

National Organ and Tissue Donation Initiative, 18

OPO standards, 34

oversight role, recommendations for, 14, 133

scientific review of transplantation system, 133

Health Care Financing Administration, 18, 34, 57

OPO oversight, 58, 132

Heart transplantation, 29

Medicaid coverage, 45

pretransplantation mortality, 93

primary nonfunction, 91

survival rates, 17

Hispanic patients

access to transplantation, 44

organ donation rates, 50-51

Histocompatibility testing, 42

I

Immunosuppressive medications, 41

Information management

computer simulation of allocation system, 95-96

cost data, 124

current inadequacies, 14, 131, 133-134

distribution of data, 134

Final Rule goals, 2-3, 24

goals, 132

impact of biological factors, 94

organ recovery and distribution, 94

outcomes data, 94, 132-133

public access, 25, 134

recommendations for, 15, 131, 134-135

regular review of procedures and performance, 134

scientific review of transplantation system, 133

for system oversight, 131-132

for system performance evaluation, 134

transplant center-based measures, 95

See also Performance measures

Insurance, access to transplantation and, 12, 39, 47

Ischemic time, 12

current knowledge and transplant practice, 92, 93-94, 98-99

definition, 17, 91

maximal achievable, 93

medically acceptable, 93

negative outcomes related to, 91, 92

organ sensitivity, 91

primary nonfunction and, 91

significance of, 17

strategies to reduce, 92

K

Kidney transplantation, 91

Medicaid coverage, 45

racial differences, 39-40, 41, 42

socioeconomic differences, 41

Suggested Citation:"Index." Institute of Medicine. 1999. Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rule. Washington, DC: The National Academies Press. doi: 10.17226/9628.
×

L

Legal liability, 3, 28

Length of stay, 127-128

Liver transplantation

allocation criteria, 25, 34, 35-37

organs recovered but not transplanted, 95

reducing retransplantation risk, 92

as unit of analysis, 28-29

Local units, 32

Lung transplantation, 29

Medicaid coverage, 45

survival rates, 17

M

Marginal donors, 93

Match system, 34-35

definition, 32

Medicaid, 22

access to transplantation and, 45-46

mandated referrals for organ donation, 57

Medicare, 18, 22

Final Rule effect on expenditures, 128

mandated referrals for organ donation, 57

performance standards, 132

Minority populations

access to transplantation, 2, 11-12, 39-40, 44

Final Rule review, 27-28

See also specific racial or ethnic group

Mortality. See Pretransplantation mortality; Survival rate, posttransplant

Multiple organ transplants, 36

N

National Marrow Donor Program, 95

National Organ and Tissue Donation Initiative, 18

National Organ Transplant Act of 1984, 2, 14, 17, 22

O

Omnibus Budget Reconciliation Act of 1986, 22, 57

OPOs. See Organ procurement organizations

OPTN. See Organ Procurement and Transplantation Network

Organ allocation areas

biological constraints, 94

computer simulations, 96

costs of increasing, 123, 129-130

effect on donor behavior, 12

patient education, 90

population size, 7, 61, 88

rationale for, 87-89

recommendations for, 6-7, 89-90

Organ Procurement and Transplantation Network (OPTN)

allocation policy, 36-37

board composition, 25-26

criticisms of governance structure, 38

current system, 5

Final Rule provisions, 24-25, 46

historical evolution, 22-23

information management, 25, 134-135

performance measures, 133

performance review, 132

policy development, 25-26

recommendations for, 15, 134-135

review of policies and procedures, 3, 23

transition to new policies, 25

Organ procurement organizations (OPOs)

administration and management, 33

certification, 18, 34

costs of organ procurement, 129-130

current system, 4

definition, 32

function, 4, 32, 33

historical evolution, 18-19, 22

host, 32

number of, 7, 32

oversight, 18, 25, 33, 58

performance standards, 34, 58-59, 132, 133

responsibilities, 19, 33, 49

service area requirements, 33

sharing agreements, 33-34

effects on transplantation rate, 82, 85

recommendations for, 89-90

Suggested Citation:"Index." Institute of Medicine. 1999. Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rule. Washington, DC: The National Academies Press. doi: 10.17226/9628.
×

size of

distribution, 78

distribution of patient status levels, 81-82

historical evolution, 19

rationale for minimum organ allocation areas, 87-89

transplant outcomes and, 78, 81, 86

transplantation rate and, 7, 78, 81-82, 86

variation in posttransplantation mortality among, 70, 74

variation in pretransplantation mortality among, 69-70, 74, 76

variation in transplantation rate among, 6-7, 69, 70, 72, 74, 76, 78, 81-82, 85, 86-87

variation in waiting times among, 61, 67, 68, 72, 74, 86, 88-89

volume of

posttransplant survival rate and, 91, 98, 99

transplant outcomes related to, 6-7, 12-13, 72, 76, 86, 88

transplantation rate and, 6, 72, 74, 76, 86, 87-88

waiting time effects on, 72

Oversight

federal role, 131-132, 133

OPO certification, 18

OPO performance standards, 34, 58-59

OPO service area requirements, 33

OPTN role, 25

participants, 131

recommendations for, 14, 131, 133

scientific review of transplantation system, 133

P

Pancreas transplantation, 45

Payment for donations, 58

Performance guidelines, 95

Performance measures, 14

outcomes, 132-133

purpose, 132

recommendations for, 131, 133

review of current, 132

waiting times as, 1, 7, 10, 61, 88

Posttransplantation mortality. See Survival rate, posttransplant

Pretransplantation mortality, 1

effects of OPO sharing agreements, 82, 83

as indicator of access, 10

national organ sharing and, 96

OPO size and, 78, 81

OPO volume and, 6, 7

patient age and, 86

variations among OPOs, 69-70

variations by patient status, 68, 69-70, 71-72, 74, 76, 82, 85, 86 , 87

waiting time and, 72

Primary nonfunction

definition, 91

ischemic time limits, 92

reducing risk of, 92

Pritsker computer model, 96

Procurement of organs

costs, 123, 129-130

determination of organ acceptability, 93

factors affecting organ availability, 50

OPO responsibilities, 4, 19, 49

process, 49

reducing retransplantation risk in, 92

system evolution, 18-19

Public awareness campaigns, 53, 56, 58

Q

Quality assurance, 95, 131

Quality control, 95

R

Recovery and preservation of organs

biological factors in, 91

costs, 129-130

current policies and procedures, 4

data collection, 95

organs recovered but not transplanted, 95

responsibility for, 4, 129

surgical procedure, 129

Required request legislation, 56-57

Suggested Citation:"Index." Institute of Medicine. 1999. Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rule. Washington, DC: The National Academies Press. doi: 10.17226/9628.
×

Retransplantation, 91

cost of Final Rule, 127, 129

donor characteristics as risk factors, 93

risk associated with increased allocation areas, 123

risk reduction, 92

Routine notification legislation, 57

S

Severity of illness

access issues in small transplant centers, 43

allocation criteria, 10, 35, 36-37

classification system, 4

cost of transplantation related to, 13, 127-129

current inadequacies in assessment, 24

current organ allocation process, 5, 6

in determination of organ acceptability, 93

effects of increased allocation areas, 1, 7

outcomes analysis method, 66-68

posttransplant survival rate and, 98

standardized criteria for defining, 26

variation in outcomes, 68, 78

waiting time and, 1, 10-11, 35, 61-62

See also specific status level of patient

Socioeconomic differences

access to transplantation, 2, 39-40, 41

policy development to reduce, 26

in posttransplantation compliance, 41

Sources of donated organs, 49

determination of organ acceptability, 93

State laws and policies, 27

mandated referrals for organ donation, 56-57

Medicaid, 45-46

Status 4 patient outcomes, 74

Status 1 patients

access issues in small transplant centers, 43

allocation criteria, 10

characteristics of patients, 62, 69

clinical features, 4

cost of transplantation, 13, 127-128

current allocation process, 5

effects of increased organ allocation areas, 1, 7, 87-88, 96

effects of OPO sharing on transplant outcomes, 82

length of stay, 127-128

OPO size as outcome factor, 78, 81

posttransplantation mortality risk, 69, 70, 98

pretransplantation mortality risk, 68, 69-70, 71-72

transplantation rate among, 1, 69, 78, 86, 87

waiting time, 10, 61-62, 66, 68, 69, 86

Status 2 patients

access issues in small transplant centers, 43

age as outcome factor, 72

allocation criteria, 10, 11, 90

characteristics of patients, 62

clinical features, 4

cost of transplantation, 13, 128

current allocation process, 5

effects of increased organ allocation areas, 1, 7, 87-89

effects of OPO sharing on transplant outcomes, 85

length of stay, 128

OPO size as outcome factor, 81

outcome predictors, 6

posttransplantation mortality risk, 72, 98

pretransplantation mortality risk, 68, 72, 74, 76, 87

transplantation rate among, 1, 72, 74, 76, 86, 87

waiting time, 10, 61-62, 66, 68, 72, 74, 86

Status 3 patients

age as outcome factor, 76

allocation criteria, 10, 11, 90

characteristics of patients, 62

clinical features, 4

cost of transplantation, 13, 128

current allocation process, 5

effects of increased organ allocation areas, 1, 7, 87-89, 96

effects of OPO sharing on transplant outcomes, 85

length of stay, 128

OPO size as outcome factor, 81

Suggested Citation:"Index." Institute of Medicine. 1999. Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rule. Washington, DC: The National Academies Press. doi: 10.17226/9628.
×

outcome predictors, 6

posttransplantation mortality risk, 74

pretransplantation mortality risk, 68, 74, 87

transplantation rate among, 1, 74, 76, 78, 86, 87

waiting time, 10, 61-62, 66, 68, 74, 86

Steatotic livers, 92

Surgical procedures, 129

Survival rate, posttransplant

biological factors in organ function, 91

data sources, 96, 98

Final Rule effects on, 12-13, 27-28, 91

method of analysis, 66-68

national organ sharing and, 96

OPO-specific risk factors, 98, 99

OPO volume related to, 12-13

racial differences, 42

risk factors, 98

status level of patient and, 98

trends, 17

variation among OPOs, 70

variations by patient status, 69, 70, 72, 74

waiting time and, 72

System of organ transplantation, 31

allocation process, 34-37

biological constraints, 94

computer simulation, 95-96

criticisms of governance structure, 38, 131

data collection and performance monitoring, 95, 131-135

evolution of, 18-23

federal role, 131-132

liver transplantation as representative of, 23

local variation, 22, 23

participants, 49

recommendations for, 14

scientific review of, 133

transplant centers and programs, 22

T

Training of medical professionals, 26

Transplantation centers

costs of organ procurement, 129-130

data collection, 95

definition, 32

number of, 22

performance standards, 132, 133

small, effects of Final Rule on, 43-45, 46

Transplantation programs, 3-4

definition, 32

estimated charges, 124

number of, 22

Transplantation utilization, 2

trends, 17

Transportation of patient

as barrier to utilization, 44-45

Medicaid coverage, 45-46

Transportation of procured organ

costs, 13, 123, 129-130

Transportation of surgical team, 129

U

United Network for Organ Sharing (UNOS)

criticisms of governance structure, 38

current structure, 22, 31

data collection and management, 134

function, 5, 31

liver allocation policy, 36-37

membership, 31

policy development, 31

Utilization

number of transplantations, 2, 17

patient's travel distance as factor in, 44-45

trends, 17

W

Waiting list, 2, 17-18

enrollment process, 3-4

Final Rule goals, 24, 26

management of, 5

multiple listings for same patient, 36

Waiting time

as allocation criterion, 10-11, 35, 87, 88-89, 90

current concerns, 1, 61

definition, 61

Suggested Citation:"Index." Institute of Medicine. 1999. Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rule. Washington, DC: The National Academies Press. doi: 10.17226/9628.
×

determinants of, 27

fairness issues, 2

Final Rule goals, 26

Final Rule review, 3, 27-28, 61

as indicator of system performance, 1, 7, 10, 61, 88

method of analysis, 66-68

racial differences, 40

regional variation, 23, 61, 62

socioeconomic differences, 39-40

transfer to another transplant center, 36

transplant outcomes and, 72, 74, 76, 86, 89

variation among OPOs, 61, 67, 68, 72, 74, 86, 88-89

variations by patient status, 68, 69, 72, 74, 86, 88-89

Suggested Citation:"Index." Institute of Medicine. 1999. Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rule. Washington, DC: The National Academies Press. doi: 10.17226/9628.
×
Page 225
Suggested Citation:"Index." Institute of Medicine. 1999. Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rule. Washington, DC: The National Academies Press. doi: 10.17226/9628.
×
Page 226
Suggested Citation:"Index." Institute of Medicine. 1999. Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rule. Washington, DC: The National Academies Press. doi: 10.17226/9628.
×
Page 227
Suggested Citation:"Index." Institute of Medicine. 1999. Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rule. Washington, DC: The National Academies Press. doi: 10.17226/9628.
×
Page 228
Suggested Citation:"Index." Institute of Medicine. 1999. Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rule. Washington, DC: The National Academies Press. doi: 10.17226/9628.
×
Page 229
Suggested Citation:"Index." Institute of Medicine. 1999. Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rule. Washington, DC: The National Academies Press. doi: 10.17226/9628.
×
Page 230
Suggested Citation:"Index." Institute of Medicine. 1999. Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rule. Washington, DC: The National Academies Press. doi: 10.17226/9628.
×
Page 231
Suggested Citation:"Index." Institute of Medicine. 1999. Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rule. Washington, DC: The National Academies Press. doi: 10.17226/9628.
×
Page 232
Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rule Get This Book
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Each day, nearly 60 Americans receive a transplanted kidney, liver, or other organ-a literal "second chance at life"-but 11 others die waiting for an organ transplant. The number of donors, although rising, is not growing fast enough to meet the increasing demand. Intended to improve the current system of organ procurement and allocation, the "Final Rule," a 1998 regulation issued by the U.S. Department of Health and Human Services, sparked further controversy with its attempts to eliminate the apparent geographic disparities in the time an individual must wait for an organ.

This book assesses the potential impact of the Final Rule on organ transplantation. It also presents new, original analyses of data, and assesses medical practices, social and economic observations, and other information on: access to transplantation services for low-income populations and racial and ethnic minority groups; organ donation rates; waiting times for transplantation; patient survival rates and organ failure rates leading to retransplantation; and cost of organ transplantation services.

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