Going the distance for procurement of donation after circulatory death livers for transplantation—Does reimbursement reflect reality?

Abstract

Donation after circulatory death (DCD) liver transplantation (LT) has increased slowly over the past decade. Given that transplant surgeons generally determine liver offer acceptance, understanding surgeon incentives and disincentives is paramount. The purpose of this study was to assess aggregate travel distance per successful DCD versus deceased after brain death (DBD) liver procurement as a surrogate for surgeon time expenditure and opportunity cost. All consecutive liver offers made to Michigan Medicine from 2006 to 2017 were analyzed. Primary outcome was the summative travel distance (spent on all attempted procurements) per successful liver procurement that resulted in LT. Donation after circulatory death liver offer acceptance was lower than DBD liver offers, as was proportion of successful procurements among accepted offers. Overall, 10 275 miles were travelled for accepted DCD liver offers, resulting in 23 successful procurements (mean 447 miles per successful DCD liver procurement). For accepted DBD liver offers, 197 299 miles were travelled, resulting in 863 successful procurements (mean 229 miles per successful DBD liver procurement). On average, each successful DCD liver procurement required 218 more miles of travel than each successful DBD liver procurement. Current reimbursement policies poorly reflect increased surgeon travel (and time) expenditures between DCD and DBD liver offers.

The Changing Landscapes in DCD Liver Transplantation

“…One question to be answered is whether transplant centers will be willing to travel substantial distances for DCD livers? A previous single-center study demonstrated that each successful DCD liver procurement required an average of 218 more miles of travel than each successful DBD liver procurement [16]. This difference was largely due to lower successful procurement proportion among DCD procurement episodes.…”

A Step toward Standardization: Results of two National Surveys of Best Practices in Donation after Circulatory Death Liver Recovery and Recommendations from The American Society of Transplant Surgeons and Association of Organ Procurement Organizations

“…Additionally, appropriate reimbursement for recovery surgeons is necessary in circumstances when the donor fails to progress to circulatory death and the recovery is not performed. This assurance will encourage the participation of experienced surgeons in these DCD recoveries 29 . We hope that this document may lead to the establishment of consistent national practices which may optimize DCD donation potential and the successful utilization of DCD livers for transplantation.…”

Safely Expanding the Liver Donor Pool by Utilization of Organs from Donation after Circulatory Death with Comparable Results to Donation After Brain Death, a Large Single-Center Experience

“…Up to half of all DCD procurements are unsuccessful as donors fail to progress to asystole or WIT exceeds 30 min. A study by the University of Michigan showed that 218 more miles was traveled for each successful DCD liver compared to successful DBD livers, which included miles traveled to donors for both DCD and DBD that were unsuccessful [ 20 ]. These increased travel and opportunity costs are undertaken by the transplant center, which may discourage some centers from aggressively pursuing DCD donors.…”