Bronsther, O

Fung, JJ

Norman, DJ

Starzl, TE

Tzakis, A

Van Thiel, D

Wood, RP

D. J. Norman

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The distribution of organs for liver transplantation

D-Scholarship@Pitt

c:i z vi :5 <'0 ~ ~ '" C(I) > ~ Q. ~ ~ (I) "0 Q. 40000 30000 20000 10000 0 --Suicide RR:4.4; p=45% RRa3.2; pz43% RRz2.4; pa41% Homicide RA=2.2: p=45% __ - RR:1.6: p=43% +-4~~~~::::::;:=;=:::;::=;:::~ RR.1.2; p=41 % 60 65 70 75 80 85 90 95 100 Prevalence of Homes Withoul Guns, % Potentially preventable homicides and suiCIdes by prevalence of homes withou1 guns: United States. 1988 through 1990. RR Indicates unadjusted risk of homICide or suicide from guns in home; and p. baseline prevalence of homes with guns. effort to kill. Also, there is no evidence of compensatory increases in homicides involving other weapons when societal firearm access is restricted. Case fatality rates for suicides attempted with a gun are much higher than for suicides attempted otherwise.s Cross-national evidence suggests that where the favored means of committing suicide is removed there is a decrease in suicide.s ~iven th~t guns are the favored means of committing suicide In the Uruted States, some people may be less likely to choose other means if denied firearm access. Suicidal people are typi-cally ambivalent about taking their lives, and the period at risk may be fleeting. Cook's view reflects our own: "The argument here is not that the availability onethal means is the sole determinant of. suicide rates but, rather, that the availability oflethal means Influences the extent to which suicidal impulses are translated into complete suicides."s The limitations of our approach include using risk esti-mates l .2 that may not accurately reflect the population's risk and not adjusting for all confounding factors (note that the adjusted risk estimates of both case-control studies were higher than the unadjusted estimates l .2). It would appear that decreasing the prevalence of guns in the home could be an important part of a national strategy to prevent homicide and suicide. Jeffrey J. Sacks, MD. MPH James A. Mercy, PhD George W. Ryan, PhD R. Gibson Parrish, MD Centers (or Disease Control and Prevention Atlanta, Ga 1. KeUennann AL. Rivara FP. RUlhCorth NB. et al. Gun ownership u a risk (actor Cor homicide In the home. N Engl J Mod. 1993;329:1084-1091. 2. Kellennann AL. Rivara FP. Somes G. et al. Suicide in the home In relation to IIIn ownership. N Engl J Mod. 1992;327:467-472. 3. Davil JA. Smith TW. Gfnmll Soci4l S,,7Wlf" 1971·1991: C"mu/atiw Coo.book. Chicago. Ill: National Data Program for the Social Scienee Series No. 12, National Opinion ResellJ"th Center; 1991:989. 4. SaJUman LE. Mercy JA. O'Carroll PW. ROll4!nberg ML. Rhodes PH. Weapon in-~=~~ and injury out.c:omes in Camily and Intimate .... ulta. JAMA. 1992',267: 5. Cook PJ. The technolollY of penonal violence. In: Tanry M. ed. Grime and JIIA· tic.: A RevitfW of R"«J.rclt. Chicago. iii: University oCChieago Preu; 1991;14:1-72. The Distribution of Organs for Liver Transplantation To the Editor.-The article by Dr Bronsther and colleagues' contained serious inaccuracies and misleading statements. The first national liver allocation protocol adopted by the United Network for Organ Sharing (UNOS) was based on a system recommended by one of the authors of the article by Bronsther et al. A preexisting, voluntary organ sharing sys-848 JAMA. September 21. 1994-Vol 272. No. 11 y~yy Approved Liver Transplant Programs· Liver Trenaplan1 Annual Annual V .. r Progrerna Net Inc_ 1_ ... % 1987 58 1988 86 8 13.8 1989 79 13 19.7 1990 85 8 7.8 1991 93 8 9.4 1992 105 12 12.9 1993 112 7 6.7 ·Table shOws the cumulative number of approved liver transplant progrems at year's end for the years shown and the percantaga increase in the number at pro-grams trom year to year. tern cal:ed UNOS STAT was continued on a voluntary basis for the sickest patients. It permitted organ procurement organi-zations to override the national allocation system and distrib-ute livers to UNOS STAT patients from the national pool of waiting patients before considering patients listed on local, region&!, and national waiting lists who ranked higher than the UNOS STAT patients for receipt of these organs. Bronsther et al incorrectly assert that allocation tended to be autoregulatory when the UNOS STAT classification was in place. To the contrary, by October 1989 the transplant community began to question the merits of UNOS STAT, because of the ease with which it could be (and the degree to which it was believed to be) abused and because it was di-recting too many organs to the sickest patients to the overall detriment of potential liver recipients in general. qh~ decision to eliminate the UNOS STAT category and substitute a more defined and monitorable classification for the most medically urgent category of patients (implemented in January 1.991) was endorsed by the UNOS Ethics Committee and supported overwhelmingly by the rest of the transplant community, including the UNOS Patient Affairs Committee. The only negative public comments received by UNOS on this change came from institutions or individuals affiliated with the transplant center of Bronsther et al and largely concentrated on issues other than the elimination of UNOS STAT, per se. Bronsther et al suggest that following the elimination of UNOS STAT, transplant centers~ther than the center with which the authors are associated-would fail to provide trans-plants for the most critical liver patients, a "stampede" of new transplant centers would be started to take advantage of the "organ-rich regions," and organs available for transplantation would d'!crease in number. In truth, from 1992 to 1993 a total of 1479 liver transplant recipients (22.7% of all liver trans-plants during this period) were in the most critically urgent status code at the time of their transplant (UNOS OPTN [Organ Procurement and Transplantation Network] data as of January 23,1994). There has been no unusual increase in the number of liver transplant programs approved after January 1,1991, compared with before January 1, 1991, as shown in the Table (UNOS membership data as of February 4, 1994). Fi-nally, the number of cadaveric organ donors in 1993 increased by 7% over the number of (cadaveric) donors in 1992. Until we have enough organs for every waiting patient, any organ allocation policy will appear unfair to someone. All national organ allocation policies involve difficult and con-troversial decisions. The system is continuously undergoing thoughtful and honest reevaluation. Distortions of facts rel-evant to this profound problem do not advance the process. Douglas J. Nonnan, MD United Network for Organ Sharing Portland, Ore I.. Bnmather O. Fung JJ. Tzakia A. Van Thiel D. StanJ TE. Prioritization and organ dlatribuUon Cor liver tranlplantation. JAMA. 1994;271:140-143. To the Editor.-I was disturbed by the article by Dr Bron-sther and colleagues l regarding the prioritization of livers for transplantation. Rather than manufacture a rationale to jus-tify their claim to a greater share of the limited pool of donor livers, the authors would better serve the transplant commu-nity by addressing the donor shortage. Alexander and Vaughn2 showed that 25% of the patients awaiting transplantation died because of the lack of a donor liver. Any discussion of liver distribution must be tempered by the fact that there are too few livers available for all potential recipients, and even if all transplants were carried out at one center, there would still be a substantial mortality rate for patients on the waiting list. As long as the number of potential recipients exceeds the supply of donor livers, any revision of the present allocaHon system would accomplish nothing more than changing the ZIP code of the patients who die awaiting transplantation. The present liver allocation system uses medical urgency as the primary determinant, but expands the potential re-cipient's choices by allowing most patients to undergo trans-plantation at a local or regional center rather than be dis-placed far from home. These new centers are not automati-cally inferior to established centers, and it is unconscionable to suggest that these centers are wasting livers and having patients receive transplants unnecessarily. All programs per-forming transplants must be approved by UNOS and are subject to the same regulations. The liver transplantation community is suffering from a maldistribution of recipients, not donors. This is clearly shown by the Veterans Affairs' (V A) system for liver transplanta-tion.3 Referral of all potential liver recipients in the V A sys-tem to a single center maldistributes recipients rather than donors. Local and regional patients are forced to compete with V A patients who add nothing to the local donor pool. It would be more equitable to offer liver transplantation through the V A systems across the country. Finally, in Pittsburgh magazine, the Transplant Institute in Pittsburgh, Pa, was described as "financially self-sufficient with an annual budget of $200 million dollars generated pri-marily from patient fees (75% to 85% were from outside the region)."4 Obviously, any change in liver distribution that decreases the ability of a center to perform transp·ar.ts at the same rate "'ill decrease an institution's income. I hope that the business aspect of liver transplantation is not the driving force in attempts to change the allocation system. In view of the discrepancy between the donor liver supply and the number of potential recipients, a daily triage is oc-curring. While the authors confirm that a limited number of critically ill patients can be salvaged with transplants, I remain unconvinced that the ilI-defined concept of "medical urgency" requires a shift back to a national distribution system. Expanding the donor pool is the only way substantially to reduce the mortality rates for patients on the waiting list for liver transplantation. R. Patrick Wood, MD Houston, Tex I. Bron8ther 0, FungJJ, Tuki. A, Van Thiel 0, Starzl TE. Prioritization and organ distribution for Jiver transplanlltion. JAMA 1994;271:140-143. 2. AlexKnder JW. Vllughn WK. The use of mMrginai donors for o'lt'Jl tranapianll' lion. Tra .... pla .. l4hm •. 1991:51:135-141. 3. !-:vKn. HW, Manninen DL, Dong fB, et aI. An economic &nalysi. of liver trans-pillnlltion: COlli, iMurance coveraae, and reimbursement. In: E Vanl R W, Manninen DL, Dong FB. TM Nu.t.iofw.J C()()JImltiw TnlIUJ)J4ftt4timt St1Idr: Fifllll R.",m. Se-attle, Wuh: Battelle-Seattle ReMardI Center; June 199\. 4. Pileclti M. Pittaburgher o(the year. Stanl'. trek. PitUburp/o.. Januuy 1994:39-4t. In Reply.-It is true that one of the authors (T.E.S.) endorsed the original organ distribution plans and in fact wrote them in May 1987 in order to prevent a UNOS default of contract obligation. One plan was for kidneys and the other for ex-trarenal organs. Disputes within the appointed o:-gr.n distri-JAMA, September 21, 1994-Vol 272, No. 11 bution committee had prevented development of the required document, What was used was taken verbatim from two impending publications describing the distribution systems already in place in Pittsburgh. l .2 The existence of these manu-scripts had been made known to UNOS by two colleagues, resulting in the last-minute recruitment of Dr Starzl. The principles of both plans are still embraced by UNOS, but with a changed meaning. Originally, overwhelming weight for liver distribution was given to urgency of need because there is no treatment option comparable with the artificial kidney. "Boutique" liver recipients called in for operation from the 19th hole of the golf course have a 90% survival, but relative risk analyses of the case material summarized by Bronsther et al suggest that they could have had an even higher survival without transplant intervention.3 The appro-priate timing of liver transplantation is everything, and re-quires a national donor pool from which the recipient popu-lation can be served, as called for by the Gore bill of 1986. After 1987 the United States was carved up into regiona among which organ movement is discouraged if not prohib-ited. During this time, UNOS committees voted that a na-tional list was not feasible in spite of irrefutable scientific evidence to the contrary. When UNOS also used the Pittsburgh kidney allocation system for its contract proposal in 1987, it was understood clearly that only the rare perfect HLA match conferred a survival advantage, and even then a surprisingly small one. Yet this nonpredictive test was adopted in increments by UNOS as the dominant factor in kidney distribution. Waiting in line lost its value, kidneys sprouted wings en route to distant places, and a UNOS committee claimed that a single national list would be impractical, even as one was imposed for dissemination of "matched kidneys." The racial bias di-rected against minorities became a national shame.· The Pittsburgh program is a founder and the single most active member of UNOS. We do not aspire to a governance role for the very reason implied by Dr Wood. The problems with UNOS are not with its network of skilled and devoted staff and procurement officers, but with the committees and governance process cited by both correspondents to support their statements. Embedded into this structure are business and professional conflicts of interest that are defended with the rhetoric of "justice" and "utility," terms used to replace the easily understood word "fairness." As soon as this is more generally perceived, the lines of authority will pass to the patients for whose benefit UNOS exists. Patients can then go to where they choose, not to where they are driven. Oscar Bronsther, MD John J. Fung, MD, PhD Andreas Tzakis, MD Thomas E. Starz1, MD, PhD University of Pittsburgh Pittsburgh, Pa David Van Thiel, MD Oklahoma Transplantation Institute Oklahoma City 1. Stanl TE, Hakala T, Tzaki. A, et al. A multifactorial system for equitable .. I_ lion of cadaveric kidney recipienll. JAMA. 1987;257:3073-3075. 2. Stanl TE, Gordon RD, Tzakil A, et &1. Equitable allocation of extl'lrenal organa: with special reference to the liver. TraMpu",t Proc. 1988;20:131·138. 3. Eghteaad B, Hroll8lher 0, Irish W, et al. Disease gravIty Knd urpncy o( need u guideline. (or Iiv@r allocation. HrpoUJl.o{w. In prell. 4. Guton RS, Ayretil. Dooley LG, Diethelm AG. Racial equity in renal tranaplan-tation. JAMA 1993;270:1352-1366. State Plana for Surrogate Declalon Making To the Editor.-The recent Law and Medicine articlel de-scribed the New York State Surrogate Decision-Making Com-mittee program. A State Substitute Medical Decision-Mak-Letters 849 

The distribution of organs for liver transplantation [3]

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The distribution of organs for liver transplantation [3]

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