Newswise — Roughly nine in 10 patients awaiting organ transplants in the United States are waiting for kidneys.
Thousands of patients on the list die each year, and thousands more come off the list because their health has worsened to the point that they are no longer considered suitable for transplants. This occurs even as a significant number of offered kidneys, currently exceeding 25%, are declined for transplantation by all U.S. transplant hospitals.
Clinicians at transplant centers are weighing complex and time-sensitive factors, as they decide whether to accept or decline kidneys offered for transplantation.
In research that is the first of its kind and that holds great potential for addressing this nationwide challenge, UNC Charlotte microeconomist Glenn Dutcher and colleagues have found significant differences in the acceptance rates among clinicians at the same transplant centers, and also among centers. The heterogeneity among clinics is greater than among clinicians at a specific facility, yet both are significant.
“Our study is the first to look at individual clinician-level heterogeneity in the actual decisions they are making,” Dutcher says. “Ultimately, we want to understand if there are distinct decision processes at the human level. Are there differences in how clinicians think about their patients and how they think about accepting deceased donor kidneys on behalf of their patients? But we first had to discover if there was uniformity in decision-making among clinicians at the same clinics or not.”
The researchers’ broad area of transplantation investigation is supported by a nearly $1.5 million R01 grant and a $450,000 R21 grant from the National Institutes of Health and National Institute of Diabetes and Digestive and Kidney Diseases.
In addition to Dutcher, authors of the research paper published in the “American Journal of Transplantation” are lead author and principal investigator Ellen Green, College of Health Solutions, Arizona State University; Jesse D. Schold, Departments of Surgery and Epidemiology, University of Colorado–Anschutz; and Darren Stewart, Department of Surgery, NYU Langone Health. This is a leading journal in its field.
Significant advance
The innovative study is an important step toward figuring out why differences occur and what they may mean for patient care — and for organizational productivity.
“Our hope is that our study will serve as a foundation for a deeper understanding of the factors influencing kidney offer acceptance decisions, ultimately leading to strategies and policies that improve the kidney transplantation process,” Green said.
Understanding the dynamics that influence clinicians’ individual decisions — beyond center-level policies or other center-level factors — could boost the number of transplants, lower the length of time people wait for transplants and improve patient outcomes. Those clinician-level factors could include experience, perceptions of risk and benefits, risk tolerance and ethical considerations.
In a leading-edge approach, the research team analyzed a large, anonymized dataset of kidney offers, linking individual clinician data from on-call records of 15 transplant centers to national transplant registry information. They looked at how the quality of donor kidneys, as measured by the Kidney Donor Profile Index and other factors, influences acceptance rates. Broadly, clinicians are less likely to accept offers for lower-quality kidneys, yet the researchers found that the degree to which the kidney quality affects decisions varies among clinics and also among clinicians.
“Our interdisciplinary research team brings extensive research experiences and insights that are essential to our work,” Green says. “Two of our colleagues, Jesse Schold and Darren Stewart, have led innovative research for years, advancing the field of transplantation medicine, and Glenn Dutcher offers innovative approaches to the economic aspects of our study. Our work would not be possible without this unique combination of our areas of expertise.”
Looking ahead
Future research by the team will explore why variations among clinicians occur, with possible influence on process and policy. As one potential outcome of the study’s findings, transplant centers could reflect on their decision-making practices.
“Transplant centers can use our findings to consider root causes for the variations we found, and to decide if there are ways to reduce those variations,” Green said. “This is particularly important when evidence suggests that conservative acceptance practices can jeopardize transplant success and patient health.”
Interventions at the clinical level could include implementing evidence-based clinical decision-support tools in the allocation process, and developing tools that illustrate the association of clinician organ acceptance patterns with patient outcomes, both before and after transplants.
“When there is variation in healthcare delivery, there is often opportunity for improvement,” Schold said. “In this context, many lives of patients across the country are at stake in a complex system. Our research provides critical insights into opportunities for improvement that can have direct impact on increasing transplant opportunities and duration and quality of life for patients with end-stage kidney disease.”
As an important possible outcome, policymakers could consider the current variations in decision-making processes within and among transplantation centers when designing interventions and allocation mechanisms, the study recommended.
Senior author Stewart, associate director of registry studies for NYU Langone Health’s Center for Surgical and Transplant Applied Research, pointed out the timeliness of this line of research. “Insights into center- and doctor-specific decision-making are increasingly relevant, since currently about a fifth of kidneys are now offered to transplant hospitals as ‘open offers,’ in which the on-call surgeon uses their discretion to determine the most clinically suitable patient to receive the kidney,” Stewart said. “This represents a 10-fold rise in open offers, which is a response to a recent broadening of the donor pool.”
The research can help leaders understand how potential policies might affect decisions, Dutcher said. “Policies at various levels can have intended and unintended consequences,” he said. “Those unintended consequences can be positive, or they can be negative.”
Common productivity theme
An applied microeconomist and associate professor in the Department of Economics in the Belk College of Business, Dutcher uses experiments, surveys, observational data and theory to answer questions in creativity and innovation, personal economics, managerial economics, remote work, game theory, health economics and behavioral economics. Research into transplant decisions fits within this broad scope because of the productivity questions embedded in the work, as Dutcher’s expertise in risk preferences and decision-making processes offers key insights into clinicians’ choices.
“As an economist, I want to understand how individuals within an organization make decisions, particularly when those decisions affect productivity,” he said. “If you look at the big strand running through my research, whether it’s looking at creativity, or remote work or health economics, my work is about productivity.”
He, like other members of the research team, is driven by discovering solutions to the real-world challenges people and organizations face, and in this work in particular, by the potential to dramatically improve the quality and longevity of people’s lives.
