Action Points

Most state programs to boost organ donation haven't worked, and it's time to try new strategies, including cutting back on heart transplantation wait listing, experts said.

Every state in the U.S. has passed at least one policy to attempt to increase organ donation over the past 2 decades, Erika G. Martin, PhD, MPH, of the University at Albany-State University of New York, and colleagues reported online in JAMA Internal Medicine.

But analysis against time trends in actual donation in United Network for Organ Sharing (UNOS) and related national databases showed no significant or robust associations with either donation rates or number of transplants for first-person consent laws, donor registries, public education, paid leave, or tax incentives created by those new policies.

That was the case "even after allowing for prolonged delays for policies to take effect" in sensitivity analyses.

The only thing that did have some modest impact was revenue policies for individuals to contribute to a protected state fund to promote organ donation, which was associated with a 5.3% increase in the absolute number of transplants, equivalent to an extra 15 transplants per state per year (P=0.03).

Notably, that effect was driven by deceased donor rather than living donor transplants, "which may indicate that such funds are being targeted toward the improvement of clinical practices to optimize the organ procurement process at the time of deceased donation."

Most policies implemented by states appear not to have gone far enough to have a real effect, Martin's group suggested.

"For instance, the maximum cash value of tax deduction policies under existing policies is approximately $600, which is markedly less than the suggested $10,000 threshold to motivate donation of a solid organ, as described in prior studies," they pointed out.

Radical Incentives

The study is a "yet another reason to get serious about meaningful reform," Sally Satel, MD, a psychiatrist at Yale University, and David C. Cronin, II, MD, PhD, a transplant surgeon at the Medical College of Wisconsin in Milwaukee, wrote in an invited commentary.

"Altruism is not enough," they wrote.

Paired kidney exchanges and domino chains for living donation will help, "but they are not intended to recruit new donors in large numbers," the group added.

Even switching to presumed consent to take organs after death unless specifically forbidden "will not yield enough new kidneys for transplant because less than 1% of deceased individuals are medically eligible to donate," they added.

Satel's group called for disruptive innovation -- "compensating donors, not simply seeking to soften the financial ramification of donation. It is time to test incentives, to reward people who are willing to save the life of a stranger through donation."

The National Organ Transplant Act makes brokered or direct cash sales between buyer and seller a felony, but doesn't actually prohibit the proposed system of in-kind, third-party compensation, they noted.

"Donors would not get a lump sum of cash; instead, a governmental entity or a designated charity would underwrite and offer them in-kind rewards, such as a contribution to the donor's retirement fund, an income tax credit, or a tuition voucher worth roughly $50,000," they wrote. "To enhance deceased donation, a funeral benefit could be offered."

"Finally, as part of their compensation package from federal or state government or charity, all rewarded live donors would be guaranteed follow-up medical care for any complications, which is not ensured now," Satel and colleagues suggested.

Balancing Heart Supply and Demand

Whatever the pilot incentives to boost donation, clinicians need to stop "overselling" the heart transplantation list, Lynne Warner Stevenson, MD, of Brigham and Women's Hospital in Boston, wrote in a special communication in the same issue.

"The ethics of allocating hearts for transplant have always recalled the classic lifeboat dilemma of how many people can be allowed to board an already overcrowded lifeboat without sinking the ship and everyone on board," she wrote.

"In recognizing our responsibilities as stewards of scarce donor hearts, we should reduce new listings for heart transplants, thus restoring balance to the waiting list and keeping the lifeboat afloat," she argued.

Heart transplant numbers have seen no increase over the past 2 decades whereas the waiting list has expanded, she noted.

"As the transplant waiting list has become longer and waiting times have increased, the major route to heart transplants has become deterioration to the most urgent priority status, which accounts for 10% of patients on the waiting list but two-thirds of transplants," she noted, pointing out that "status 1A was intended to be used only in rare urgent cases."

Meanwhile, status 2 patients have little hope of getting a transplant anytime soon but often curtail their travel and participation in family events to be ready in case a donor heart becomes available, Stevenson noted.

"More realistic triage to ventricular assist devices as lifetime (destination) therapy, rather than to a long transplant waiting list, would encourage patients and families to more fully embrace and adapt their lives to enjoy maximal benefit from mechanical circulatory support," she wrote.

Putting more and more patients onto an "oversold" list undermines the promises and outcomes of transplant listing, she argued.

It's time to start saying no to wait listing patients less likely to fare well with a transplant and only add as many patients to the waitlist as are removed, she said.

"If new listings for heart transplants were reduced by 20% to 25%, the waiting list in the United States could reach a steady state close to 1,000 within 5 years," she noted, which might be doable by dialing back the contraindications for transplant that have been stretched over the years.

Martin and co-authors disclosed no relevant relationships with industry.

Satel and Cronin disclosed no relevant relationships with industry.

Stevenson disclosed support by the William T. Young Sr and Jr Foundation and grants from the National Heart, Lung, and Blood Institute for related work with the INTERMACS registry of mechanical circulatory support and the National Heart Failure Network.

• Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine

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