Provider Competition and Organ Transplant Outcomes

There is no financial mechanism to balance the demand and supply of human transplant organs. Organ supplies fall short of demands. When organs must come from deceased donors, the supply cannot be easily changed, because only 3 in 1,000 people die in a way compatible with donation. Improvement in efficiency must come from a better match between organs and the recipients. Our research here is on the matching mechanism for heart transplants.

Identification of potential donors, and matching of available hearts to recipients are administered by Organ Procurement Organizations, non-profit organizations coordinating donations within a donor service area. A key step of the donation process is the match run, which ranks potential recipients once a donor is identified. The heart is first offered to the highest ranked potential recipient on this list. If the transplant physician rejects the match, the heart is offered to the second highest ranked on the list. The process continues under either a match is found or the heart is deemed unrecoverable. We analyze the effect of a policy change in the allocation rules that determine the match run.

For transplants, the US is geographically divided into donor service areas; a potential donor is someone who dies in one of these locations. Transplant programs are located in these areas. Before 2006, when a heart became available, the match run would first rank recipients from transplant programs in the deceased donor service area. The heart then would only be offered to areas farther away if the match failed in the donor’s service area. Recipients on the local area were given priority, regardless of the severity level. After 2006, the match run would rank recipients of higher severity, first within the donor service area, then within a 500-mile radius of the donor location. If all these higher severity recipients rejected the match, the heart would be offered to lower severity patients, starting again with the local area. The change was intended to improve organ and transplant match qualities.

We take the change in the match run and allocation rules as a quasi-experiment. On the one hand, the organ supply remains unaffected by the changes in match run allocation rules. On the other hand, these changes lead to changes in competition between transplant programs. We use within-heart-transplant programs’ degree of competition variations over time to identify policy change effects. We further explore between-provider variations in transplant programs for heart and other organs to ascertain if the policy effects are limited to heart transplant programs.

The data combine information from all organ transplants between 1999 and 2016, curated by the Organ Procurement and Transplantation Network, and from the Scientific Registry of Transplant Recipients. These include detailed information on donors, recipients, donor service areas, and transplant programs. We are thus able to measure the effect of the allocation rule change on a set of outcomes related to donors, recipients and provider behavior. We show there is no spillover effect to other organ transplant programs.