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

项目摘要/摘要 美国等待肝脏移植的人数超过了3000多例 每年都有人。尽管供体肝脏短缺，10%的供体肝脏在质量上被认为是“边缘”的，并被丢弃 每年一次。边缘供肝(MDL)具有更高的风险特征，如心脏死亡后的捐赠 (DCD)、老年、脂肪变性和国家共享。通过仔细的供受者匹配，MDL可以被使用 在不影响患者生存的情况下，权衡器官质量风险和等待“更好”的风险 管风琴。因此，MDL是一种未充分利用但有价值的可移植肝脏来源。 尽管越来越多的证据表明MDL的治疗效果良好，但这种做法的采用率仍然很高 不同中心的变量。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，并确定流程改进的领域。我们的中心假设 MDL的使用在不同的移植中心是不同的，甚至在同一地区，并且受到捐赠者的影响， 受援国，以及制度因素。我们提出了一种混合方法来确定与 使用国家移植登记数据和对新英格兰移植的定性访谈的MDL利用 中锋。我们将使用一个新的数据库对捐赠者和接受者之间的器官捐献进行定量研究 分配匹配运行结果，以确定影响外科医生或中心决定的捐赠者和接受者因素 接受MDL移植。接下来，为了阐明决定移植MDL的关键步骤，我们将 对新英格兰肝脏移植中心的移植外科医生进行半结构化采访，以 确定移植MDL的障碍和促进者，重点关注外科医生的决策和结构 或中央层面的系统性影响。 我们提议的研究将解构决定移植一个人的复杂决策 MDL.我们预计这项研究的结果将确定流程改进和政策的可行目标 发展。这项工作将为研究移植中心的实践和外科医生提供一个框架 决策。通过将重点放在新英格兰作为该提案的定性部分，我们将展示 在较小的区域层面上的可行性，并打算在以后将我们的方法和结果推广到其他 区域合作，最终激发区域推动的协作进程改进努力。 从这项工作中获得的知识有可能通过以下方式增加获得肝移植的机会 优化利用现有器官。通过执行这项工作，Cron博士将在 定性方法论和临床移植科学，促进他发展成为独立的 外科医生兼科学家，移植外科领域的领军人物。

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.