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Transplant surgeons sometimes reject a poor quality liver in hopes of getting a better organ later

When an organ is obtained from a cadaveric donor, patients on the transplant waiting list are ranked (with the sickest patients placed at the top of the list in their respective regions), and the organ is offered by phone to patients with matching blood type and their doctors in descending order. Despite the scarcity of organs suitable for transplant, 45 percent of livers and similarly high percentages of other types of organs are rejected by the first surgeon to whom they are offered. It appears that surgeons reject low quality organs (for example, from patients who die of stroke versus trauma) for organs from relatively healthy patients in the hope that they will be offered a better organ in the future, explains David H. Howard, Ph.D., of Emory University.

For the study, which was supported in part by the Agency for Healthcare Research and Quality (National Research Service Award training grant T32 HS00055), Dr. Howard used data from the U.S. national transplant registry to develop a model of the surgeon's decision to accept or reject organs. He specifically analyzed data on all liver transplants performed between April 1994 and the end of 1997, excluding pediatric patients, previously transplanted patients, and multiple organ recipients. During this period, the United Network for Organ Sharing used a three-level status system to rank patients on the waiting list, with status 1 being the sickest patients (expected to live less than a week without a transplant) and status 3 being the least sick.

The author used this system to characterize the health status of patients at the time they were transplanted in order to capture surgeons' subjective judgment about patients' level of time-varying health. Status 3 patients, who are placed at the bottom of regional lists, received fewer low-quality organs (38 vs. 43 percent) than status 1 and 2 patients, reflecting the propensity of their surgeons to reject poor quality organs. Dr. Howard suggests that surgeons may have an incentive to reject organs that would lower their hospitals' survival rates. However, he notes that the problem may be self-remedying, since an ever-growing waiting list provides new incentives to accept poor quality organs.

See "Why do transplant surgeons turn down organs? A model of the accept/reject decision," by Dr. Howard, in the Journal of Health Economics 21, pp. 957-969, 2002.

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