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Transplant organ 'gaming' alleged

By ED SUSMAN, UPI Science News

WEST PALM BEACH, Fla., March 9 (UPI) -- Some of the most respected cardiologists and heart surgeons at some of the nation's most renowned hospitals apparently have engaged in the practice of "gaming" patients -- rating their heart-transplant candidates as sicker than they really were to obtain a precious donated heart for them.

"Our study has important implications for transplant policy," said Dennis Scanlon, assistant professor of health policy and administration at Pennsylvania State University in University Park. "We have shown that when transplant-listing criteria are too broad and not subject to verification, transplant centers facing greater competition for ... organs will game the system."

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In addition, Scanlon said, in his article published Tuesday in the March/April issue of the journal Health Affairs: "We have also demonstrated that more specific transplant listing policies can effectively reduce gaming. We encourage the transplant community to continue to monitor the system for recurrence of gaming behavior. Because pressure to game the system may increase over time, there is a need to remain vigilant to the possibility that gaming will return."

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Scanlon explained the system is gamed because when an organ becomes available for transplant, patients who are sicker are given top priority. By sending their patients to intensive care units or claiming that a particular patient is in critical need of an organ when that need is exaggerated, surgeons can give their patients a greater chance of being selected to receive an organ.

The need to procure a heart is a life-or-death struggle for critically ill patients, due in large part to the shortage of suitable hearts being donated.

In 2003, for example, 1,174 heart transplants were performed, but 3,517 people are waiting for a heart, according to the United Network for Organ Sharing in Richmond, Va., the agency that distributes donated organs.

"I have heard about gaming indirectly," said Dr. James Ferguson Jr., associate director of cardiovascular research at the Texas Heart Institute at Baylor College of Medicine in Houston. "I would be astonished if it didn't happen."

Ferguson added, however, gaming is not done because doctors are attempting to be dishonest or deceptive.

"This is not nefarious," he told United Press International. "The driving force behind gaming is not malevolent. You want to provide your individual patient with everything you can possibly do to give them the best chance to survive. We know that the longer a person waits for a heart and the sicker the person is when he gets a heart, the less likely there will be a good outcome."

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In the United States transplant centers are divided into 55 regions to reduce transportation time that could damage a donor organ. When a heart becomes available, UNOS looks to place that organ within the same region.

The researchers saw little gaming in regions where there was only one transplant facility, but some regions have as many as nine centers.

"Transplant centers are under pressure to get their own patients transplanted," said Peter Ubel, associate professor of internal medicine at the University of Michigan Medical School, Ann Arbor, the senior author of the study. "If the patient is on the fence between priority levels, the tendency is to push the patient over the fence to get the transplant to happen."

In their analysis of patient waiting lists from all 55 regions between 1995 and 2000, the researchers said whenever there was competition for an organ, the patients were more likely to be listed in the sickest category -- and the system was more likely to be gamed.

In 1999, UNOS changed its rules to tighten allocation after allegations of gaming arose.

"Although we did not find evidence of gaming after 1999, suggesting the new policy regulates the system effectively, the competition driving gaming still exists," Scanlon said.

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Prior to the 1999 rule change, patients awaiting heart transplants were listed in one of two categories, with the highest priority given to those expected to live less than six months without a transplant.

Generally, patients who required artificial devices to keep their heart working or who were hospitalized in an intensive care unit were automatically classified as Status 1, the highest priority. Their status did not need to be clinically verified and doctors could leave their patients on the Status 1 list as long as they wanted.

In areas with more than one heart transplant center, this left a high possibility that doctors might exaggerate their patients' conditions or even admit patients to an intensive care unit prematurely to boost their chances of receiving a transplant.

"Our study does not conclusively demonstrate that the listing practices occurring through 1998 were deliberate or dishonest," Scanlon said. "Determining the prognosis of patients with end-stage heart disease is an imprecise science and some of the influence of competition on listing decisions could have been subconscious."

He also suggested some institutions might have looked at other hospitals in the region and copied their gaming practices.

The new rules divide patients into three status levels, with the highest priority reserved for patients expected to live only one month. Doctors are required to recertify their patients on this list every seven to 14 days.

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Scanlon reported that once the rules were in place, the more competitive transplants centers did not have higher numbers of patients listed in either of the two highest priority levels. The researchers theorize the new rules have created a tougher threshold, making it difficult to exaggerate.

Although the researchers looked specifically at gaming for heart transplant patients, they said the same problems exist for other organs.

For example, in 2003, the University of Illinois settled a $2.3 million lawsuit alleging it gamed the system to increase liver transplants at its hospital in the late 1990s -- although the hospital admitted no wrongdoing. Rules for ranking liver transplant candidates also have changed recently to make gaming more difficult.

"Even with these new guidelines for heart transplants, there's still suspicion of gaming," Ubel said. "It might just be a matter of time before people learn to game the new system."

Ferguson said an inelegant political analogy to gaming might be so-called pork barrel legislation. Legislators attempt to utilize the resources of government to best serve their constituency, even though that might mean another area does not receive funds.

If there were enough organs available for all the patients who required them, the incidence for gaming would disappear or be dramatically reduced, he added.

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Ed Susman covers medical research for UPI Science News. E-mail [email protected]

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