Don't Throw Your Heart Away: Decision Processes Explain the High Discard Rate of Pediatric Donor Hearts

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PROJECT SUMMARY/ABSTRACT Heart transplant is the therapeutic gold standard for children with end-stage heart failure. Surprisingly, most pediatric transplant teams refuse at least one - if not several - of the donor hearts each of their patients is offered. Indeed, almost half of all hearts offered to pediatric candidates through the UNOS allocation system are discarded altogether. In light of the high waitlist mortality rates for children waiting heart transplants, the pattern of donor discard indicates a need to better understand the behavioral factors underlying transplant team decision making. Previous literature suggests that federal regulatory agencies place too much emphasis on post- transplant outcomes when auditing program performance. Additionally, publicly available outcome assessments for transplant programs do not make salient that some programs tend to reject many of the hearts they are offered, whereas other programs accept a broader range of donor offers. Taken together, both federal regulators and public reports incentivize transplant teams to maximize transplant success above other outcomes, and programs may respond by using selective donor acceptance strategies to achieve this goal. This project uses a framework from behavioral economics—blending the scientific disciplines of conventional economics and decision psychology— to uncover the decision processes that influence donor evaluation. The central hypothesis is that decisions surrounding the tradeoff between waitlist time and transplant success depend on what outcome information is presented for evaluation and how that information is presented, which we address through two specific aims: (1) Evaluate the association between transplant mortality rates and subsequent donor offer refusal rates at pediatric heart transplant centers; (2) Examine how the presentation of performance information affects transplant center evaluations by laypersons, patients, and clinical personnel. Hierarchical linear modeling of pediatric heart transplant data from the Organ Procurement and Transplant Network database is used to identify whether center-level low performance evaluations are associated with subsequent increases in donor refusal for quality reasons (Aim 1). Empirical studies are used to test whether performance data that reflect center donor acceptance rates influence laypersons, patients, and other stakeholders to evaluate centers with high organ decline rates less favorably than centers with low organ decline rates (Aim 2). The proposed research is innovative because although psychological influences surrounding donor evaluation have been acknowledged, behavioral research has not yet been applied to the challenge of donor discard in practice. This project provides ideal training for a future physician-scientist through exposure to a high-stakes issue at the intersection of clinical medicine, behavioral research, and health policy. The training plan incorporates an interdisciplinary panel of mentors with expertise in contemporary data science and behavioral research methods. Completion of the proposed studies could support future transplant regulatory policies that function to optimize donor evaluation, improving long-term survival of children in need of heart transplants.