Livers for transplant should be allocated across larger, more populous regions to boost the odds of a match for patients in the most urgent need, said a report released last week by a committee of the Institute of Medicine, a branch of the National Academy of Sciences.
The current system favoring local matches first "works reasonably well, but significant improvements in its fairness and its effectiveness could be made" said committee Chairman Edward Penhoet.
The recommendations, if adopted, would lead to wider sharing of organs and improve the chances for patients who urgently need transplants, regardless of the location of their hospitals.
Congress requested the IOM report last year as controversy swirled over proposed changes in the system for allocating scarce organs for transplant. The IOM recommendations generally support a regulation published by HHS in 1998 that was halted short of implementation by Congress.
In response to objections by the United Network for Organ Sharing, a Richmond, Va.-based private contractor that oversees the organ allocation program, Congress enacted a one-year moratorium on the HHS plan that expires on Oct. 21.
The IOM report recommended that:
* Waiting times be discontinued as a criterion for the vast majority of patients in line for transplant.
* HHS should be more active in overseeing organ transplantation.
* HHS should establish an external, independent scientific review board to assist in setting and monitoring transplant policy.
* HHS should set better performance measures to evaluate the system and make relevant data broadly available.
Last week, HHS Secretary Donna Shalala said the government intends to revise the final regulation and to "move vigorously" to put it into effect.
Reactions to the IOM report were mixed.
"They came up with the same conclusion that every other group that's looked at this has," said John Fung, M.D., a transplant surgeon at the University of Pittsburgh Medical Center Health System. Fung, an outspoken critic of UNOS, supported the regulatory changes proposed by HHS and generally praised the IOM's findings.
"It's pretty clear they want broader sharing and to allow patients to get access to data on waiting time," he said. "Those are issues we've been clamoring for."
UNOS also claimed victory while digging in against more direct HHS involvement. In a memo to members last week, UNOS President William Payne wrote: "We recognize that as long as there is an organ shortage, no system can meet every need. Nevertheless, the IOM concluded that the allocation system for livers is reasonably equitable for the most urgent statuses and that UNOS administers the system even-handedly."
The IOM report apparently did little to resolve the UNOS-HHS conflict.
Payne wrote that the pending regulations should be withdrawn because the IOM report "questioned the basic medical premises" behind them. He opposed the recommendation that HHS be more directly involved in the transplant system, saying current law mandates that "crucial medical decisions about transplantation should be made by the medical community. Only Congress can decide whether to change that standard."