estimating latent demand for organ...
TRANSCRIPT
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Estimating latent demand for organ transplantation
Presentation before the Maryland Health Care Commission working group
May 27, 2015
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How can we quantify latent demand for organ transplantation?
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The current formulaThe current formula is complicated, but ultimately carries several flawed assumptions:
• The rate of ESLD/ESRD in a DSA is fully captured by the current number of transplants to residents
• If the current number of transplants to residents of a DSA is declining, then need is declining
• A new center won't change the proportion of patients in a DSA who go elsewhere for a transplant (ex-migrants)
• A new center won't change the proportion of patients who come from outside a DSA for a transplant (in-migrants)
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The current formulaThe current formula is complicated, but ultimately carries several flawed assumptions:
• The rate of ESLD/ESRD in a DSA is fully captured by the current number of transplants to residents
• If the current number of transplants to residents of a DSA is declining, then need is declining
• A new center won't change the proportion of patients in a DSA who go elsewhere for a transplant (ex-migrants)
• A new center won't change the proportion of patients who come from outside a DSA for a transplant (in-migrants)
These assumptions are probably more reasonable for (say) stroke, where supply isn't constrained
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Proposed framework: estimating demand
• Base demand on number of cases of ESRD/ESLD
• Ex-migrants (in excess of some baseline) represent unmet local demand
• Formula must be easy to calculate
• Estimate demand independent of case mixture(currently, white/high-SES patients have better access to transplant, but we don't wish to perpetuate this disparity)
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Estimating latent demand: methods
• Data: KT in 2013; incident ESRD in 2011 (most recent years available)
• Define "exmigrant" KT as KT outside of DSA of residence
• Regress # exmigrant KT as a function of # incident ESRD cases with no constant term (i.e. model ratio of KT to ESRD cases)
• If observed exmigrant KT is dramatically larger than predicted exmigrant KT, this indicates latent demand for a new transplant center
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Estimating latent kidney demand
Wide variation among DSAs
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Estimating latent kidney demand
WRTC rate of travel is 3x national average (40.3 expected, 123 observed)
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Liver transplantation
• We have no registry of ESLD
• Model exmigrations as a proportion of all transplants, by DSA of residence
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Estimating latent demand: liver
• We have no registry of ESLD; use transplants by DSA of residence for denominator
• Regress # exmigrant LT as a function of transplants to residents, with no constant term
• If observed exmigrant LT is dramatically larger than predicted exmigrant LT, this indicates latent demand for a new transplant center
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Estimating latent liver demand
Even more variation among DSAs
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Estimating latent liver demand
WRTC rate of exmigration is 2.3x average (21.6 expected, 49 observed)
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Conclusion
Based on national averages, WRTC has latent demand for an estimated 83 additional KT and 27 additional LT per year
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Estimates are conservative
• Does not account for population growth
• Does not account for potential inmigration
• A center that was more aggressive than the national average with regards to outreach or live donation might capture additional demand