Continuous allocation score design for guaranteeing equity and reducing discards in kidney and liver transplantation

连续分配评分设计，保证肾移植和肝移植的公平性并减少丢弃

• 批准号: 10587447
• 负责人: Allan B Massie
• 金额: $ 73.73万
• 依托单位: NEW YORK UNIVERSITY SCHOOL OF MEDICINE
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-12-17 至 2027-11-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10587447
• 关键词: Address; Affect; Age; Algorithms; American; Antibodies; Biological; Black race; Blood; Blood typing procedure; Cessation of life; Characteristics; Childhood; Clinical; Collaborations; Communities; Complex; Data; Dimensions; Disparity; Ensure; Equity; Ethics; Ethnic Origin; Evolution; Frustration; Gender; Geography; Goals; HLA Antigens; Hospitals; Incidence; Ischemia; Kidney; Kidney Transplantation; Life; Liver; Logistics; Matched Group; Methodology; Methods; Natural experiment; Organ; Organ Procurements; Organ Transplantation; Outcome; Participant; Policies; Policy Maker; Population; Race; Rest; Rural; Solid; Stigmatization; Subgroup; System; Testing; Time; Transplantation; Wait Time; Waiting Lists; Weight; behavior change; combinatorial; design; dynamic system; ethnic disparity; flexibility; geographic disparity; improved; interest; liver transplantation; mathematical methods; mortality; mosaic; organ allocation; organ procurement transplantation network; racial disparity; simulation; social health determinants; socioeconomic disparity; socioeconomics; tool; transplant centers

PROJECT ABSTRACT The benefits of kidney and liver transplantation should be available to all Americans, but geographic, racial/ethnic, gender, and other disparities, plus a shortage of transplantable organs, have frustrated that promise. Because organ allocation is a complex system in which every factor prioritized affects how other factors are prioritized, policy changes that focus on one aspect (e.g. geographic disparity or panel reactive antibody) in isolation often fail. Prior allocation changes have often resulted in unintended consequences. The Organ Procurement and Transplantation Network (OPTN) has resolved to eliminate geographic boundaries in favor of continuous allocation through implementation of a composite allocation score (CAS). However, eliminating geographic boundaries impacts the rest of the system. To design a CAS for continuous allocation that retains priorities of the current system without introducing unintended disparities requires simulation optimization methods. These methods will maximize the survival benefit of transplantation while ensuring equity by making transplant rates similar among populations that differ by race, gender, and social determinants of health. To address the challenge of kidney and liver continuous allocation, we propose to efficiently apply simulation and explore a vast number of alternative designs to choose a CAS that eliminates geographic boundaries, as per the OPTN mandate, without inducing unintended new disparities. This system will minimize waitlist deaths and maximize life-years gained from transplant, while assuring transplant rates for relevant subgroups (e.g. by age, race, ABO blood type, urban/rural) comparable to the current system. We then propose to improve on the CAS by making incidence rate ratios (the relative transplant rates between races, genders, sensitization levels, etc.) closer to 1. Whether perfect equity along all these dimensions can be achieved is an open question, but we will attempt to equalize access for every candidate. Finally, we will explore ways the CAS might minimize discard of transplantable organs. We will use previously unavailable timestamp data on organ offers to create a logistics and discard simulation that will predict how allocation changes impact cold ischemia time and discards for the first time. Using this new tool, we will test prioritizing offers to centers and candidates most likely to accept them, while maintaining equity of access. The score can adapt flexibly as transplant center acceptance criteria change. Our findings will be immediately and directly applicable to national conversations regarding kidney and liver allocation, using an approach that optimizes outcomes and supports transparency, an ethical cornerstone in transplantation. Our methodology allows stakeholders to enforce constraints on equity and outcomes in clinically detailed simulations of organ allocation. In this era of continuous allocation, we can achieve more transplants–and assure they are more equitably distributed–than ever before.

项目摘要 所有美国人都应该享受肾移植和肝移植的好处，但地理、 种族/民族、性别和其他差异，再加上可移植器官的短缺，都阻碍了这一点 承诺。因为器官分配是一个复杂的系统，其中每个优先考虑的因素都会影响其他因素 因素被优先考虑，政策变化集中在某一方面（例如地理差异或小组反应） 抗体）的分离常常会失败。先前的分配变更常常会导致意想不到的后果。这 器官获取和移植网络 (OPTN) 已决定消除器官获取和移植网络的地理界限 有利于通过实施综合分配评分（CAS）进行连续分配。然而， 消除地理边界会影响系统的其余部分。设计连续分配的 CAS 保留当前系统的优先级而不引入意外的差异需要模拟 优化方法。这些方法将最大限度地提高移植的生存效益，同时确保 通过使不同种族、性别和社会背景的人群之间的移植率相似来实现公平 健康的决定因素。为了应对肾脏和肝脏连续分配的挑战，我们建议 有效地应用仿真并探索大量替代设计，以选择可消除 根据 OPTN 的授权，地理边界不会引起意外的新差异。这个系统 将最大限度地减少候补死亡人数并最大限度地延长移植获得的生命年，同时确保移植率 与现行系统相当的相关亚组（例如，按年龄、种族、ABO 血型、城市/农村）。我们 然后建议通过制定发病率比率（不同时期之间的相对移植率）来改进 CAS 种族、性别、敏感度水平等）更接近 1。是否可以在所有这些维度上实现完美的公平 是否实现是一个悬而未决的问题，但我们将努力为每位候选人提供平等的机会。最后，我们将 探索 CAS 尽可能减少可移植器官丢弃的方法。我们将使用以前不可用的 器官上的时间戳数据可用于创建物流和丢弃模拟，以预测分配方式 变化影响冷缺血时间并首次丢弃。使用这个新工具，我们将测试优先级 向最有可能接受的中心和候选人提供录取通知书，同时保持平等的机会。分数可以 随着移植中心接受标准的变化灵活适应。我们的调查结果将立即直接 适用于有关肾脏和肝脏分配的全国对话，使用优化的方法 结果并支持透明度，这是移植的道德基石。我们的方法允许 利益相关者在器官的临床详细模拟中对公平性和结果施加限制 分配。在这个持续分配的时代，我们可以实现更多的移植，并确保它们更多 比以往任何时候都更公平地分配。