A mixed-methods approach to identify factors determining utilization of marginal quality deceased donor livers for transplantation

项目总结/摘要 美国肝脏移植等待名单上的移植数量超过3，000例 人每年。尽管如此短缺，10%的供体肝脏被认为质量“边缘”并被丢弃 每年。边缘供体肝脏（MDLs）具有较高的风险特征，例如心脏死亡后的捐赠 (DCD)老年、脂肪变性和国家共享。通过仔细的捐赠者-接受者匹配，可以使用MDLs 在不影响患者生存的情况下，权衡器官质量风险与等待“更好”的风险， 器官.因此，MDLs代表了一种未充分利用但有价值的可移植肝脏来源。 尽管有越来越多的证据表明MDLs的良好结果，但采用这种做法仍然存在。 各中心之间存在差异。为了解释这一点，我们这个项目的目标是检查 MDL移植的决策制定，并确定流程改进的领域。我们的核心假设 MDLs的使用在不同的移植中心有所不同，即使在同一地区，也会受到捐赠者的影响， 接受者和机构因素。我们提出了一种混合方法的方法来确定相关的因素， 使用国家移植登记数据和新英格兰移植定性访谈评估MDL的使用 中心.我们将使用一个新的数据库， 分配匹配运行结果，以识别影响外科医生或中心决定的供体和受体因素， 接受MDL进行移植。接下来，为了阐明决定移植MDL的关键步骤，我们将 对来自新英格兰肝移植中心的移植外科医生进行半结构化访谈， 识别移植MDL的障碍和促进因素，重点关注外科医生的决策和结构 或者是在中央层面的系统影响。 我们提出的研究将解构移植一个新的基因的决定背后的复杂决策。 MDL。我们希望这项研究的结果将确定可操作的目标，为过程改进和政策 发展这项工作将提供一个框架，研究移植中心的做法和外科医生 决策的通过关注新英格兰的定性部分，我们将展示 在较小区域层面上的可行性，以便稍后将我们的方法和结果扩展到其他区域 区域，最终激发区域驱动的协作过程改进的努力。 从这项工作中获得的知识有可能通过以下方式增加肝移植的获得 优化可用器官的使用。通过执行这项工作，Cron博士将接受以下方面的指导培训： 定性方法和临床移植科学，促进他发展成为一个独立的 外科医生兼科学家，移植手术的领导者。

Project Summary/Abstract The liver transplant waitlist in the United States exceeds the number of transplants performed by over 3,000 people annually. Despite this shortage, 10% of donor livers are considered “marginal” in quality and discarded annually. Marginal donor livers (MDLs) have higher risk characteristics such as donation after cardiac death (DCD), older age, steatosis, and national sharing. With careful donor-recipient matching, MDLs can be used without compromising patient survival, weighing organ quality risks against the risk of waiting for a “better” organ. MDLs therefore represent an underutilized but valuable source of transplantable livers. Despite a growing amount of evidence showing good outcomes for MDLs, adoption of this practice remains variable across centers. In attempt to explain this, our objective with this project is to examine the process of decision-making for MDL transplantation and to identify areas for process improvement. Our central hypothesis is that use of MDLs varies across transplant centers, even within the same region, and is influenced by donor, recipient, and institutional factors. We propose a mixed-methods approach to identify factors associated with MDL utilization using national transplant registry data and qualitative interviews with New England transplant centers. We will perform a quantitative study of donor-recipient organ offers using a novel database of allocation match run results to identify donor and recipient factors influencing a surgeon or center’s decision to accept an MDL for transplant. Next, to elucidate key steps in the decision to transplant an MDL, we will conduct semi-structured interviews with transplant surgeons from New England’s liver transplant centers to identify barriers and facilitators to transplanting MDLs, with a focus on surgeon decision-making and structural or systemic influences at the center level. Our proposed research will deconstruct the complex decision-making underlying the decision to transplant an MDL. We expect the results of this study will identify actionable targets for process improvement and policy development. This work will provide a framework for studying transplant center practices and surgeon decision-making. By focusing on New England for the qualitative portion of this proposal, we will show feasibility on a smaller regional level with the intention to later scale our methods and results across other regions, ultimately inciting regionally driven efforts of collaborative process improvement. The knowledge acquired from this work has the potential to increase access to liver transplantation by optimizing use of available organs. By performing this work, Dr. Cron will receive mentored training in qualitative methodology and clinical transplantation science, facilitating his development into an independent surgeon-scientist and a leader in transplant surgery.