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Original Research |

Decision Making in Liver Transplant Selection Committees: A Multicenter Study

Michael L. Volk, MD, MSc; Scott W. Biggins, MD, MAS; Mary Ann Huang, MD, MS; Curtis K. Argo, MD, MS; Robert J. Fontana, MD; and Renee R. Anspach, PhD, MSW
[+] Article and Author Information

From the University of Michigan and University of Michigan Health System, Ann Arbor, and Henry Ford Health System, Detroit, Michigan; University of Colorado, Aurora, Colorado; and University of Virginia, Charlottesville, Virginia.


Grant Support: By the Greenwall Foundation (Drs. Volk and Anspach) and by grant NIH K23DK085204 from the National Institutes of Health (Dr. Volk).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-1200.

Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Volk (e-mail, mvolk@med.umich.edu). Data set: Not available.

Requests for Single Reprints: Michael L Volk, MD, MSc, Division of Gastroenterology and Hepatology, University of Michigan Health System, 300 North Ingalls Street, 7C27, Ann Arbor, MI 48109; e-mail, mvolk@med.umich.edu.

Current Author Addresses: Dr. Volk: Division of Gastroenterology and Hepatology, University of Michigan Health System, 300 North Ingalls Street, 7C27, Ann Arbor, MI 48109.

Dr. Biggins: Anschutz Outpatient Pavilion, 7th Floor, 1635 Aurora Court, Mail Stop B-154, Aurora, CO 80045.

Dr. Huang: Division of Gastroenterology and Hepatology, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202.

Dr. Argo: Division of Gastroenterology and Hepatology, University of Virginia Health System, Box 800466, Charlottesville, VA 22908.

Dr. Fontana: Division of Gastroenterology and Hepatology, University of Michigan Health System, 3912 Taubman Center, Ann Arbor, MI 48109.

Dr. Anspach: Department of Sociology, University of Michigan, 4109 LSA, 500 South State Street, Ann Arbor, MI 48109.

Author Contributions: Conception and design: M.L. Volk, R.R. Anspach.

Analysis and interpretation of the data: M.L. Volk, S.W. Biggins, C.K. Argo, R.J. Fontana, R.R. Anspach.

Drafting of the article: M.L. Volk, S.W. Biggins, R.R. Anspach.

Critical revision of the article for important intellectual content: M.L. Volk, S.W. Biggins, C.K. Argo, R.J. Fontana, R.R. Anspach.

Final approval of the article: M.L. Volk, S.W. Biggins, C.K. Argo, R.J. Fontana.

Provision of study materials or patients: S.W. Biggins, M.A. Huang, C.K. Argo.

Obtaining of funding: M.L. Volk, R.R. Anspach.

Administrative, technical, or logistic support: S.W. Biggins.

Collection and assembly of data: M.L. Volk, S.W. Biggins, M.A. Huang, C.K. Argo, R.R. Anspach.


Ann Intern Med. 2011;155(8):503-508. doi:10.7326/0003-4819-155-8-201110180-00006
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Background: To receive a liver transplant, patients must first be placed on a waiting list—a decision made at most transplant centers by a multidisciplinary committee. The function of these committees has never been studied.

Objective: To describe decision making in liver transplant committees and identify opportunities for process improvement.

Design: Observational multicenter study.

Setting: 4 liver transplant centers in the United States.

Participants: 68 members of liver transplant committees across the 4 centers.

Measurements: 63 meetings were observed, and 50 committee members were interviewed. Recorded transcripts and field notes were analyzed by using standard qualitative sociologic methods.

Results: Although the structure of the meetings varied by center, the process was uniform and primarily involved inductive reasoning to review possible reasons for patient exclusion. Patients were excluded if they were too well, too sick (in the setting of advanced liver disease), or too old or had nonhepatic comorbid conditions, substance abuse problems, or other psychosocial barriers. Dominant themes in the discussions included member angst over deciding who lived or died, a high correlation between psychosocial barriers to transplantation and the patient's socioeconomic status, and the influence of external forces on decision making. Unwritten center policies and confusion regarding advocacy versus stewardship roles were consistently identified as barriers to effective group decision making.

Limitations: The use of qualitative methods provides broad understanding but limits specific inferences. The 4 centers may not reflect the practices of every transplant center nationwide.

Conclusion: The difficult decisions made by liver transplant committees are reasonably consistent and well-intentioned, but the process might be improved by having more explicit written policies and clarifying roles. This may inform resource allocation in other areas of medicine.

Primary Funding Source: The Greenwall Foundation and the National Institutes of Health.

Figures

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Figure.
Views of 45 transplant committee members on the functioning of their committee.

The scale reflects the number of times each topic was mentioned as a problem or strength. Strengths and weaknesses were not formulated a priori but were constructed afterward on the basis of issues spontaneously voiced by members in response to open-ended questions (a measure of salience [12]).

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Comments

Submit a Comment
Social factors merit a more standardized approach in liver transplant evaluation
Posted on October 27, 2011
Anna, Flattau, Paul Meissner, Paul J. Gaglio, and John F. Reinus
Montefiore Medical Center
Conflict of Interest: None Declared

In their description of how liver transplant selection committees decide which candidates will be listing for transplantation, Volk et al (1) remark that psychosocial factors often lead to 'protracted and contentious' discussion. We propose that the evaluation process for transplant candidates ought to attempt a more standardized approach to assessing social barriers to care.

Volk et al state that candidates who 'stood out from a psychosocial perspective' might be approved for listing despite medical problems, and that socioeconomic status correlated with concern for psychosocial barriers to transplantation. Social barriers, which are determined by the patient's environment and thus are distinct from psychological issues, may indeed limit a patient's ability to adhere to post-transplant care and therefore affect the ability of the patient to undergo the procedure. However, clinicians' subjective judgments of patients from different socioeconomic or ethnic groups may or may not reflect the reality of patients' social resources and ability to overcome challenges in their lives, particularly for ethnic groups that are underrepresented in the medical field or for people living in poverty.

Our work has shown that nearly half of liver transplant programs in the United States use no formal evaluation tool to evaluate social barriers to transplantation, and that two-thirds of programs routinely stop evaluations prior to listing because of social support issues.(2) The fact that social inclusion criteria are largely subjective and vary both within and between transplant centers reflects the uncomfortable status quo around the issue of social barriers to care, and demonstrates the need for a more systematic approach to this issue. In the case of variable and often subjective social exclusion criteria, it may be difficult in practice to distinguish between health care providers' judgment of social barriers and their racial or class prejudices. Research addressing the expansion of transplant criteria to socially isolated patients requires a systemic approach to social vulnerability, in which we define, study, and reduce barriers to care.(3) An explicit approach to social criteria for transplant reduces the risk that practitioners will substitute prejudice for evidence-based assessment of a patient's appropriateness for listing.

References

(1) Volk ML, Biggins SW, Huang MA, Argo C, Fontana R, Anspach R. Decision Making in Liver Transplant Selection Committees: A Multicenter Study. Annals of Internal Medicine, 2011: 155(8),503-508.

(2) Flattau A, Olaywi M, Gaglio PJ, Marcus P, Meissner P, Dorfman EBL, Reinus JF. Social barriers to listing for adult liver transplantation: their prevalence and association with program characteristics. Liver Transplantation, 2011: 17(10),1167-75.

(3) Hogan BE, Linden W, Najarian B. Social support interventions: do they work? Clinical Psychology Review, 2002:22, 381-440.

Conflict of Interest:

None declared

Decision Making in Liver Transplant Selection in developing countries
Posted on November 24, 2011
Levent, Filik, Consultant
Research Hospital
Conflict of Interest: None Declared

Dear Sir,

I read with great interest recent article by Volk et al. I appreciate the researchers for this excellent study. They investigated the factors having role in decision making in liver transplantation" thoroughly in United States. I agree with all the conclusions of the study however there are some other pitfalls in emerging or developing countries. Transplantation committees in meeting in Turkey should consider some other facts in decision making for liver transplantation. First item is local sociocultural patterns or especially opinions of family or tribal leaders especially in rural areas. Efforts of a family or a tribe to find a living donor candidate for an important patient within family is unvarying. That's why face-to-face interviews are conducted with detailed open ended questions with donor candidate is performed. Unwillingly donor candidates are eliminated confidentially. However, this situation might sometimes make the committee give priority for the patient. Another important issue is number of inexperienced transplantation teams. In emerging countries, newly developed tranplantation teams are more frequent than developed countries. These teams could tend to give priority for relatively lower risk patients for successfull outcomes.

References

Volk ML, Biggins SW, Huang MA, Argo CK, Fontana RJ, Anspach RR. Decision Making in Liver Transplant Selection Committees. Ann Intern Med. 2011;155:503-508.

Conflict of Interest:

None declared

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