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

项目总结/摘要 心脏移植是治疗终末期心力衰竭儿童的金标准。令人惊讶的是，大多数 儿科移植团队拒绝至少一个-如果不是几个-他们的每个病人提供的捐赠心脏。 事实上，通过UNOS分配系统提供给儿科候选人的所有心脏中几乎有一半是 完全丢弃。考虑到等待心脏移植的儿童的高死亡率， 捐献者丢弃表明需要更好地了解移植团队决策背后的行为因素 制作。以前的文献表明，联邦监管机构过于强调后， 移植结果时，审计程序的性能。此外，公开的结果评估 因为移植计划并没有突出表明，一些计划往往会排斥他们所接受的许多心脏。 提供，而其他计划接受更广泛的捐助者提供。总的来说，联邦监管机构 公开报告激励移植团队最大限度地提高移植成功率， 方案可以通过使用选择性捐助者接受战略来实现这一目标。该项目使用了 从行为经济学的框架-融合传统经济学的科学学科， 决策心理学-揭示影响捐助者评价的决策过程。核心假设 等待时间和移植成功之间的权衡取决于结果 提供信息以供评估，以及如何提供信息，我们通过两个方面来解决这一问题。 具体目标：（1）评估移植死亡率与随后拒绝捐赠者之间的关系 儿童心脏移植中心的比率;（2）检查性能信息的呈现如何影响 由外行、患者和临床人员对移植中心进行评估。分层线性模型 来自器官获取和移植网络数据库的儿科心脏移植数据用于识别 中心一级的低绩效评估是否与随后拒绝捐助者的增加有关， 质量原因（目标1）。实证研究被用来检验是否表现数据，反映中心捐助者 接受率影响外行，患者和其他利益相关者评估高器官中心 下降率低于器官下降率低的中心（目标2）。拟议的研究是 创新性是因为虽然人们已经认识到围绕捐助者评价的心理影响， 行为研究尚未应用于实践中供体丢弃的挑战。这个项目提供 理想的培训，为未来的医生，科学家通过接触高风险的问题，在交叉的临床 医学、行为研究和卫生政策。培训计划包括一个跨学科小组， 具有当代数据科学和行为研究方法专业知识的导师。完成 拟议的研究可以支持未来的移植监管政策，以优化供体评估， 提高需要心脏移植的儿童的长期存活率。

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.