State by state variations in organ donation policy in the U.S. have little effect: JAMA Internal Medicine

The Effect of State Policies on Organ Donation and Transplantation in the United States  
Paula Chatterjee; Atheendar S. Venkataramani ; Anitha Vijayan ; Jason R. Wellen; Erika G. Martin

JAMA Intern Med. Published online June 01, 2015. doi:10.1001/jamainternmed.2015.2194


Abstract:
"Importance  Shortages in transplantable solid organs remain a critical public health challenge in the United States. During the past 2 decades, all states have implemented policies to increase organ supply, although their effectiveness is unknown.

Objective  To determine the effects on organ donation and transplantation rates of state policies to provide incentives for volunteer donation.

Design, Setting, and Participants  Using a quasi-experimental design and difference-in-differences regression analyses, we estimated the effect of policies in all 50 states and the District of Columbia on organ donors per capita and the number of transplantations from January 1, 1988, to December 31, 2010. Analyses were also stratified by type of donor (living vs deceased). Data were derived from the United Network for Organ Sharing. All data collection occurred between July 7 and September 27, 2013.

Exposures  Policies of interest were the presence of first-person consent laws, donor registries, dedicated revenue streams for donor recruitment activities, population education programs, paid leave for donation, and tax incentives. Information on states’ passage of various policies was obtained from primary legislative and legal sources.

Main Outcomes and Measures  The number of organ donors and transplantations per state, per year, during the study period.

Results  From 1988 to 2010, the number of states passing at least 1 donation-related policy increased from 7 (14%) to 50 (100%). First-person consent laws, donor registries, public education, paid leave, and tax incentives had no robust, significant association with either donation rates or number of transplants. The establishment of revenue policies, in which individuals contribute to a protected state fund for donation promotion activities, was associated with a 5.3% increase in the absolute number of transplants (95% CI, 0.57%-10.1%; P = .03). These associations were driven by a 4.9% increase in organ donations (95% CI, 0.97%-8.7%; P = .01) and an 8.0% increase in transplants (95% CI, 3.1%-12.9%; P = .001) from deceased donors as opposed to changes among living donors or transplants from living donors.


Conclusions and Relevance  Nearly all state-level policies to encourage organ donation have had no observable effect on the rate of organ donation and transplantation in the United States. The one exception was the establishment of revenue policies to promote organ donation, which may have led to small increases in organ donations and transplantations from deceased donors. New policy designs are needed to increase donation rates and curtail the widening gap between organ supply and demand."

Contagion, for good and ill

Frank Bruni had a recent NY Times column that reminded me of the chain of high school suicides:
"Between May 2009 and January 2010, five Palo Alto teenagers ended their lives by stepping in front of trains. And since October of last year, another three Palo Alto teenagers have killed themselves that way, prompting longer hours by more sentries along the tracks. The Palo Alto Weekly refers to the deaths as a “suicide contagion.”

Sometimes something similar happens with good acts, and I was reminded of that by this recent story from Israel (about a different kind of chain of kidney donations than I usually write about):

Chain Reaction of Good Will
"Avraham Shapira donated a kidney to a stranger and set off a series of altruistic gestures. A few months later his cousin, Yehuda Rabinovich, was inspired by Shapira and also donated a kidney to a stranger. From there the movement spread around the Shomron region. So far six people have donated kidneys to complete strangers."

Expanding non-directed kidney donation: the Renewal model

An article in the Forward talks about attempts to expand the successful organ donation program of Renewal beyond the Jewish community:
Can an Orthodox Charity Help Save Lives in This Man's Church?

"Although 90% of Renewal’s donors are ultra-Orthodox, about half their recipients are people like Sarna, who come from the broader Jewish community.

"The average wait time for a kidney through Renewal is six to nine months.

"Because many ultra-Orthodox rabbis believe that organ donation from dead bodies is against Jewish law, Renewal focuses solely on live donors. That puts Renewal’s donors in an extremely rare group of several hundred Americans who, each year, donate their kidney altruistically to a stranger.
...
"Researchers are studying Renewal’s model to see whether it can be replicated in other race- and faith-based communities. Meanwhile, one African-American transplant surgeon is setting up a group modeled on Renewal in a prominent Harlem church.

"Anthony Watkins, an assistant professor of surgery at Weill Cornell Medical College, has witnessed Renewal’s work firsthand, ever since he began his transplant fellowship six years ago. “I’ve always thought that what Renewal does is spectacular and fantastic and [that] maybe this could be duplicated in other communities,” he said.

"Watkins thinks that by using Renewal’s model — appealing to African Americans to help fellow African Americans — he can persuade people to donate in greater numbers. “I think once you establish a good rapport and knowledge and education… you can get altruistic donors to step forward,” Watkins said. But how many people are willing to donate a live organ to a stranger?
...
"Renewal facilitates an average of about 50 kidney transplants a year. About three-quarters of those transplants are ultra-Orthodox donors giving to a Jewish stranger.

"Ultra-Orthodox Jews account for just 0.2% of America’s population. Yet last year, by the Forward’s estimates, they accounted for up to 17% of the people who donated a kidney to strangers.

"Rees realized that if Renewal’s model of communally focused organ donation could be extrapolated to the general population, it could create tens of thousands of additional kidney donors. The waiting list could be reduced to zero. “That’s what Renewal has achieved,” Rees said, “and that is nothing short of amazing.”

"Rees contacted Duke University to see if researchers there could investigate whether Renewal’s model could be replicated in Christian communities.

"Last year, two Duke professors, David Toole and Kim Krawiec, put together an interdisciplinary team of faculty and students, including lawyers, physicians, sociologists and theologians, to examine new methods of increasing living kidney donation.
...
"Renewal leads donors and recipients through every stage of the transplant process. It is particularly important for kidney donors, who receive very little financial support from insurance companies and the state. Renewal covers lost wages, transportation and any necessary hotel costs. It also offers domestic support such as house cleaning, laundry services and catering. Reiner said that the average cost of a transplant, including the group’s administrative overhead, is about $20,000.
...
"The United Network for Organ Sharing, which tracks donations nationally, counts a kidney donation as “altruistic” only if the donor does not specify to whom the kidney is given. Last year it tracked 180 such altruistic donations.

"Because Renewal’s donors choose the recipient of their kidney — even though they have no personal relationship with them — UNOS categorizes them in a larger pool of 1,273 living donors who directed their kidney to a “non-relative.”

"Based on this method, Renewal’s donors account for about 2% or 3% of living donations to non-family members.

"But Duke University’s Toole says that it is unfair to compare Renewal’s donors to most other donors in this larger pool because most of those donors know the recipient of their kidney. Renewal’s donors give to strangers. “What makes the model so interesting,” Toole said, is that “it’s some in-between space” between directed donations and altruistic donations."
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See my earlier post on Renewal here.