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

项目摘要/摘要 心脏移植是治疗终末期心力衰竭儿童的黄金标准。令人惊讶的是，大多数 儿科移植团队拒绝了每个患者收到的至少一个--如果不是几个--捐赠者的心脏。 事实上，通过联合国操作系统分配系统向儿科候选人提供的几乎一半的心脏是 完全被抛弃了。鉴于等待心脏移植的儿童等待死亡率很高，这种模式 捐赠者放弃表明有必要更好地了解支持移植团队决策的行为因素 制作。以前的文献表明，联邦监管机构过于强调后 审计程序性能时的移植结果。此外，公开提供的结果评估 因为移植计划并不能突出一些计划倾向于排斥许多心脏。 提供，而其他方案接受更广泛的捐赠者提供。加在一起，这两个联邦监管机构 公开的报告激励移植团队将移植成功最大化，而不是其他结果，以及 项目可以通过使用选择性接受捐赠者的战略来实现这一目标。此项目使用 来自行为经济学的框架-融合传统经济学的科学学科和 决策心理学--揭示影响捐赠者评估的决策过程。中心假说 围绕等待时间和移植成功之间权衡的决定取决于结果 提供信息以供评估，以及如何呈现该信息，我们通过两个 具体目标：(1)评估移植死亡率和随后的供者拒绝之间的关系 儿科心脏移植中心的比率；(2)检查表现信息的呈现如何影响 非专业人员、患者和临床人员对移植中心的评估。分层线性建模 来自器官采购和移植网络数据库的儿科心脏移植数据用于识别 中央一级的低绩效评价是否与随后的捐助者拒绝人数增加有关 质量原因(目标1)。实证研究被用来检验反映中心捐赠者的业绩数据 接受率影响外行人、患者和其他利益相关者对高器官中心的评估 器官衰退率低于器官衰退率较低的中心(目标2)。拟议的研究是 创新是因为尽管围绕捐赠者评估的心理影响已经得到承认， 行为研究尚未被应用于实践中对捐赠者丢弃的挑战。该项目提供了 对未来的医生-科学家的理想培训，通过暴露于临床交叉点的高风险问题 医学、行为研究和卫生政策。该培训计划包括一个跨学科的小组， 具有当代数据科学和行为研究方法专业知识的导师。已完成的 拟议的研究可能会支持未来的移植监管政策，以优化捐赠者的评估， 改善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.