The New German Allocation System for Donated Thoracic Organs Causes Longer Ischemia and Increased Costs

Abstract

Objective: Allocation criteria changed in 2000 as a result of Germany's new transplantation law. Before, thoracic organs were primarily allocated electively within the donor region (according to urgency and waiting time). Afterwards, all patients in Germany eligible for heart transplants were registered in a national waiting list. With the exception of high-urgency patients that are approved by an audit committee, waiting time has become the major criteria for allocation. In this study, we investigated the impact of the new allocation system on economic aspects as on clinical results. Methods: One year in the new allocation system (NA) was compared to the previous year in the old allocation system (OA) regarding explantation/transportation distance, costs, ischemia time and clinical outcome. All explantations performed by our institution within Germany were evaluated. Results: The number of transplantations and the spectrum was similar between the two time periods (NA vs. OA: 61 vs. 57 overall). Eighty-two percent of these explanted organs were transplanted within the donor region in the OA time period, but only 37 % in the NA period. This resulted in higher transportation distances (NA: 441 ± 177 km vs. OA: 179 ± 118 km), higher transportation cost (NA: EUR 4,472 ± 2,858 per explantation vs. OA: EUR 1,858 ± 2,293 explantation, p = 0.001), and therefore longer ischemia times in the NA period (NA: 264 ± 56 min: OA: 208 + 61 min, p = 0.001). Perioperative results and survival after a mean clinical follow-up of 21 ± 8 (OA) and 11 ± 5 (NA) months were comparable (86 % vs. 87 % (p = 0.93). Conclusion: Transportation distance, costs for explantation and ischemia time increased significantly with the NA period. While the clinical short-term outcome proved to be comparable, we cannot yet judge the long-term impact of the prolonged ischemia time on the development of chronic rejection.

Key words

Allocation - costs - ischemia - outcome

References

• 1 Deutsche Stiftung Organtransplantation .Entwicklung der Organspenderzahlen. Jahresbericht 2001; DSO-Verlag Neu-Isenburg 2001
• 2 Halasz N A. Medicine and ethics. How to allocate transplantable organs.  Transplantation. 1991;  52 (1) 43-46
• 3 Gesetz über die Spende, Entnahme und Übertragung von Organen (Transplantationsgesetz -TPG). BGBL. IS. 2632-42; §2; §12 5. .Nov. .1997
• 4 Schulz U, Tenderich G, Minami K. et al . Ergebnisse der orthotopen Htx von Patienten nach den HU-Richtlinien im Vergleich zur elektiven Transplantation konventionell gemeldeter Empfänger.  Transplantationsmedizin. 2001;  Suppl 148-149
• 5 Snell G I, Griffiths A, Macfarlane L. et al . Maximizing thoracic organ transplant opportunities: The importance of efficient coordination.  J Heart Lung Transplant.. 2000;  19 (4) 401-407
• 6 Petzold T, Feindt P R, Kalweit G. et al . Effects of modification of the allocation system on ischemia duration and costs of heart transplantation. Transplantation Cooperation UNI-NRW.  Thorac Cardiovasc Surg.. 1999;  47 (3) 153-156
• 7 Schmid C, Deng M C, Gradaus R. et al . Impact of local donor and regionalization on a German transplantation center. UNI NRW. Universities of North Rhine Westfalia.  Transpl Int.. 1999;  12 (2) 141-144
• 8 Pflugfelder P W, Thomson D, Singh N R, Menkis A H, McKenzie F N, Kostuk W J. Cardiac allograft ischemic time. Relation to graft survival and cardiac function.  Circulation. 1989;  80 ((5 Pt 2)) III116-121
• 9 Muller C, Furst H, Reichenspurner H. et al . Lung procurement by low-potassium dextran and the effect on preservation injury. Munich Lung Transplant Group.  Transplantation. 1999;  2768 (8) 1139-1143
• 10 Keck B M, Bennett L E, Rosendale J. et al .Worldwide thoracic organ transplantation: a report from the UNOS/ISHLT International Registry for Thoracic Organ Transplantation. Clin Transpl 1999: 35-49
• 11 Beckurts K T, Jauch K W, Holscher A H. et al . Regionalization of donor organ procurement: first experiences in southern Bavaria and results of a regional donor hospital survey.  Transpl Int. 1996;  9 (Suppl 1) 5464-5468
• 12 Luciani G B, Faggian G, Livi U, Mazzucco A. Variables affecting clinical results after heart transplantation using older donors.  Transplant Proc. 1992;  24 (6) 2681-2683
• 13 Livi U, Caforio A L. Heart donor management and expansion of current donor selection criteria.  J Heart Lung Transplant.. 2000;  19 (8 Suppl) S43-48
• 14 Kohler H. Organtransplantation in Bayern. In: Deutsche Stiftung Organtransplantation - Jahresbericht 2001.  Neu-lsenburg. 2002;  2002 23-24