Does competition for transplantable hearts encourage 'gaming' of the waiting list?

Health Affairs

Volumn 23, Issue 2, 2004, Pages 191-198

  Scanlon, Dennis P ^a   Hollenbeak, Christopher S ^b   Lee, Woolton ^a   Loh, Evan ^c   Ubel, Peter A ^d  

^a PENNSYLVANIA STATE UNIVERSITY   (United States)

^b PENN STATE COLLEGE OF MEDICINE   (United States)

^c PFIZER INC   (United States)

^d UNIVERSITY OF MICHIGAN   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; COMPETITION; DISEASE SEVERITY; HEALTH CARE POLICY; HEART TRANSPLANTATION; HOSPITAL ADMISSION; HUMAN; MARKET; MONITORING; PATIENT CARE;

EID: 1842780018     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.23.2.191     Document Type: Article

References (19)

1. University Renal Research and Education Association, United Network for Organ Sharing, 2000 Annual Report of the U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: Transplant Data 1989-1999, 18 February 2000, www.optn.org/data/annualReport.asp (16 December 2003).
2. J.F. Burdick, J. DeMeester, and I. Koyama, "Understanding Organ Procurement and the Transplant Bureaucracy," in Transplantation, ed. L.C. Ginnis, A.B. Cosimi, and P.J. Morris (Malden, Mass.: Blackwell Science, 1999), 875-896.
3. A.M. Harper et al., "The United Network for Organ Sharing/Organ Procurement and Transplantation Network Waiting List and Donor Registry," in Clinical Transplants 1998, ed. J.M. Cecka and P.I. Terasaki (Los Angeles: UCLA Tissue Typing Laboratory, 1998), 73-90.
4. See the discussion in A.C. Anyanwu, C.A. Rogers, and A.J. Murday, "Variations in Cardiac Transplantation: Comparisons between the United Kingdom and the United States," Journal of Heart and Lung Transplantation 18, no. 4 (1999): 297-303; and T.V. Votapka et al., "Heart Transplantation Charges: Status 1 versus Status 2 Patients," Journal of Heart and Lung Transplantation 14, no. 2 (1995): 366-372. A rise of 17.4 percent in the proportion of Status 1 patients and a concurrent decline of 33 percent in Status 2 patients across all heart transplant centers between 1988 and 1995 is cited in D.J. Whellan et al., "Heart Transplant Center Practice Patterns Affect Access to Donors and Survival of Patients Classified as Status 1 by the United Network for Organ Sharing," American Heart Journal 140, no. 3 (2000): 443-450.
5. See the discussion in A.C. Anyanwu, C.A. Rogers, and A.J. Murday, "Variations in Cardiac Transplantation: Comparisons between the United Kingdom and the United States," Journal of Heart and Lung Transplantation 18, no. 4 (1999): 297-303; and T.V. Votapka et al., "Heart Transplantation Charges: Status 1 versus Status 2 Patients," Journal of Heart and Lung Transplantation 14, no. 2 (1995): 366-372. A rise of 17.4 percent in the proportion of Status 1 patients and a concurrent decline of 33 percent in Status 2 patients across all heart transplant centers between 1988 and 1995 is cited in D.J. Whellan et al., "Heart Transplant Center Practice Patterns Affect Access to Donors and Survival of Patients Classified as Status 1 by the United Network for Organ Sharing," American Heart Journal 140, no. 3 (2000): 443-450.
6. See the discussion in A.C. Anyanwu, C.A. Rogers, and A.J. Murday, "Variations in Cardiac Transplantation: Comparisons between the United Kingdom and the United States," Journal of Heart and Lung Transplantation 18, no. 4 (1999): 297-303; and T.V. Votapka et al., "Heart Transplantation Charges: Status 1 versus Status 2 Patients," Journal of Heart and Lung Transplantation 14, no. 2 (1995): 366-372. A rise of 17.4 percent in the proportion of Status 1 patients and a concurrent decline of 33 percent in Status 2 patients across all heart transplant centers between 1988 and 1995 is cited in D.J. Whellan et al., "Heart Transplant Center Practice Patterns Affect Access to Donors and Survival of Patients Classified as Status 1 by the United Network for Organ Sharing," American Heart Journal 140, no. 3 (2000): 443-450.
7. As defined by admission to an ICU with a requirement for inotropic agents or with need for continuous indwelling central hemodynamic monitors or both, or who requires mechanical assistance. See UNOS, "Resources, Policies," www .unos.org/policiesandbylaws/policies.asp? resources=true (10 October 2003).
8. As defined by the need for continuous intravenous inotropic therapy. See Whellan et al., "Heart Transplant Center Practice Patterns."
9. This support must include implantation of left (or right) ventricular assist device, total artificial heart, intra-aortic balloon pump, or extra-corporeal membrane oxygenator (ECMO). Patients at Status 1A on mechanical circulatory support or ventilation need recertification every fourteen days, while those needing infusion of inotopes need recertification every seven days. See UNOS, "Resources, Policies."
10. Votapka et al., "Heart Transplantation Charges"; and Anyanwu et al., "Variations in Cardiac Transplantation".
11. Votapka et al., "Heart Transplantation Charges"; and Anyanwu et al., "Variations in Cardiac Transplantation".
12. See, for example, T.M. Burton and A. Merrick, "U.S. Alleges Liver-Transplant Fraud," Wall Street Journal, 29 July 2003; S. Warmbir, "UIC Hospital Sued for Medicare Fraud," Chicago Sun-Times, 29 July 2003; and M. O'Connor, "Hospitals Accused of Transplant Fraud," Chicago Tribune, 28 July 2003.
13. See, for example, T.M. Burton and A. Merrick, "U.S. Alleges Liver-Transplant Fraud," Wall Street Journal, 29 July 2003; S. Warmbir, "UIC Hospital Sued for Medicare Fraud," Chicago Sun-Times, 29 July 2003; and M. O'Connor, "Hospitals Accused of Transplant Fraud," Chicago Tribune, 28 July 2003.
14. See, for example, T.M. Burton and A. Merrick, "U.S. Alleges Liver-Transplant Fraud," Wall Street Journal, 29 July 2003; S. Warmbir, "UIC Hospital Sued for Medicare Fraud," Chicago Sun-Times, 29 July 2003; and M. O'Connor, "Hospitals Accused of Transplant Fraud," Chicago Tribune, 28 July 2003.
15. The HHI for each OPO is the sum of squares of the market shares of each transplant center. We calculated market share as the percentage of transplants performed by each center in its OPO. In the extreme case, when there is only one transplant center in an OPO, that center will have a market share of 100 percent, and the relevant HHI will take on a value of 10,000 (we rescaled to 1 in our analysis). At the other extreme, there are many transplant centers in an OPO, each with less than 1 percent of the total market share, resulting in an HHI near zero.
16. We first tested whether the presence of any competition had an impact on listing status. This was done using a binary indicator for OPOs with only one transplant center. Results (not shown) suggested that competition was a significant predictor of listing status, so we proceeded to study the importance of the degree of competition. More centers in an OPO may increase the incentive to game if the result is to drive down the average number of transplants per center, making it relatively less likely for a center to receive an organ.
17. Our model equates the proportion (under a logit transformation) of transplant center i's patients in OPO j at time t that are listed in the most severe illness category (Status 1 prior to 1999 and Status 1A after 1999) to a sum involving an estimated constant and a zero mean, normally distributed error term plus two products involving estimated model parameters and vectors covering transplant center specific characteristics (for example, aggregate patient demographic characteristics) and OPO-specific characteristics (for example, the number of transplant centers and the HHI). To account for the clustering of transplant centers within OPOs, we assumed OPO and transplant center random effects and fitted the data to a linear mixed effects model. See N.M. Laird and J.H. Ware, "Random Effects Models for Longitudinal Data," Biometrics 38, no. 4 (1982): 963-974. A detailed methods appendix is available from Dennis Scanlon, dpscanlon@psu.edu.
18. We defined "list turnover" as the total number of transplants performed annually in the OPO divided by the total annual size of the waiting list in the OPO. List turnover measures the frequency by which patients listed in an OPO receive transplants. Low turnover could result in longer waiting times and increased illness severity of listed patients and could raise the number of patients listed as Status 1/1A independent of competition.
19. R.C. Starling, "Economics of Heart Transplantation," in Primer on Transplantation, ed. D.J. Norman and W.N. Suki (Thorofare, N.J.: American Society of Transplant Physicians, 1998), 405-407.