Matched trade and Chain Donor Transplants: Decrease the Waitlist Manage Center Finances .

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Paired exchange and Chain Donor Transplants: Decrease the Waitlist & Manage Center Finances. Jeffrey Veale, M.D., Kidney Transplant Surgeon, Director of the Donor Exchange Program, Assistant Professor - UCLA Medical Center Debbie Mast, Financial/Database Manager, Stanford Hospital and Clinics
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Combined trade and Chain Donor Transplants: Decrease the Waitlist & Manage Center Finances Jeffrey Veale, M.D., Kidney Transplant Surgeon, Director of the Donor Exchange Program, Assistant Professor - UCLA Medical Center Debbie Mast, Financial/Database Manager, Stanford Hospital and Clinics Sean Van Slyck, Director of Procurement, CTDN

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Questions to keep running on: Is my Transplant Center investigating all potential outcomes in diminishing the hold up rundown, including matched and chain gift? What openings/hindrances to achievement do I find in the matched/chain contributor handle? In what manner can your OPO help with matched trades/chain transplantation?

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The Problem Kidney Exchanges… A New Paradigm 80,000 individuals anticipating kidney transplants 16,000 transplants performed yearly List keeps on extending auxiliary to corpulence, diabetes and seniority

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Possible Solutions Prolong allograft life span Calcineurin inhibitor free conventions Immune checking Expand the contributor pool Xenotransplantation Paying givers Accepting minor kidneys (ECD, DCD… ) Utilizing incongruent benefactors

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Utilizing Incompatible Donors At slightest 33% of patients with a ready living benefactor are barred because of blood classification and cross match contrariness JAMA 2005 35% of any two people will be ABO inconsistent 30% of beneficiaries sharpened to allo-HLA because of past transplants, pregnancies or transfusions

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Options Desensitization programs Paired benefactor trades "SWAP" Chains Combination (of the above)

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Desensitization Programs Advantages Expands the giver pool Friend/adored one gives to proposed beneficiary Disadvantages Very costly – Additional $28,979 (JAMA 2005) Decreased join survival rates (AJT 2004, 2009) 1 yr 84% (versus 96%) 5 yr 69% (versus 81%) Decreased patient survival rates (AJT 2004) 5 yr 87% (versus 94%)

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Paired Donor Exchanges "SWAP" First U.S. trade performed under little attention in 2000 at Rhode Island Hospital Slow to get on because of NOTA 1984 "unlawful to secure organ in return for significant thought" Johns Hopkins and University of Cincinnati early pioneers Office of legitimate direction "trades don\'t abuse NOTA" March 28, 2007 Opened the entryway for UNOS and individual focuses to create contributor trade programs

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Paired Donor Exchanges "SWAP" Advantages Expands the giver pool Greater feeling of fulfillment by helping 2 beneficiaries Disadvantages Donors anesthetized at the same time Donors regularly travel Challenging coordinations Multiple working rooms, specialists, medical caretakers… Compared to chain transplantations Decreased nature of matches Decreased amount of matches D R

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NEJM 2009

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Chains Concept initially proposed by Dr. Michael Rees, a Urologist at the University of Toledo First U.S. chain propelled in July 2007 and so far has encouraged 10 transplantations including six transplant focuses in five distinct states First California chain propelled in July 2008 and up to this point has encouraged 8 transplantations including 4 transplant focuses in two unique states First cross-country transplant chain First "out-of-succession" transplant chain

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First California Chain

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Altruistic Donor New York, NY July 30, 2008 D1 Cousin of R1 Los Angeles, CA R1 Los Angeles, CA July 24, 2008 D2 Husband of R2 Los Angeles, CA R2 Los Angeles, CA July 24, 2008 D3 Son of R3 Los Angeles, CA R3 Los Angeles, CA October 2, 2008 D4 Wife of R4 Los Angeles, CA R4 Los Angeles, CA October 2, 2008 D5 Husband of R5 Los Angeles, CA R5 Los Angeles, CA November 19, 2008 D6 Wife of R6 Palo Alto, CA R6 Palo Alto, CA November 19, 2008 D7 Wife of R7 New York, NY R7 New York, NY November 19, 2008 D8 Brother of R8 San Francisco, CA R8 San Francisco, CA To be planned The chain may proceed

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Chains D Advantages Potential for the biggest extension of the benefactor pool since the historic point mind demise act in 1981 (UDDA) Great feeling of fulfillment for givers Helping numerous beneficiaries Additional patients on the holding up rundown climb and into the recently abandoned spots Easier Logistics Donors don\'t should be anesthetized at the same time Donors don\'t have to venture out If contributor neglects to give, chain closes yet no hopeless mischief to beneficiary R

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NEJM 2009

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Chains: Increased quality and amount of matches

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28.0 Deceased Donor Kidneys Living Donor Kidneys 17.8 14.2 10.5 7.8 7.1 Standard Criteria Donors 0-5 Antigen Match Standard Criteria Donors 6 Antigen Match Extended Criteria Donors 0-5 Antigen Match Extended Criteria Donors 6 Antigen Match Living Donors 0-5 Antigen Match Living Donors 6 Antigen Match Clinical Transplants 2005

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Chain Disadvantages Donate to an outsider rather than your adored one Some contend favorable position, as more noteworthy passionate reward knowing different beneficiaries advantage from gift Billing Problem basically comprehended (Debbie Mast and Nanci Flores) Requires transplant focuses to receive another disposition Cooperation between focuses instead of rivalry Shipping living benefactor kidneys

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Software-Matching Options Johns Hopkins New England Program for Kidney Exchange (NEPKE) Paired Donation Network (PDN) Alliance For Paired Donation (APD) Silverstone Solutions-Matchmaker National Kidney Registry (NKR)

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National Kidney Registry No cost 30 focuses over the United States California Members include: CPMC, Stanford, UCLA, UCSF (Sharp Memorial?) Aetna=2,500 patients on expired giver holding up rundown Superior coordinating programming Facilitated the most chain transplantations (51 hitherto)

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Chains: How to wind up included? Step 1

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Step 2 Enter combine into the National Kidney Registry Phone 1-800-936-1627 No cost No identifiers required Donor/beneficiary, age, blood classification, HLA antigens and antibodies

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Step 3 Matches will be organized Communication between focuses is key Coordinators - orchestrate records to be traded and affirm points of interest Surgeons - believe each other OPOs - transport living benefactor kidneys

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A New Paradigm At minimum 33% of patients with a ready living contributor are avoided because of blood classification and cross match contradiction This is the main chance to generously build the giver pool by using amazing organs, as opposed to only tolerating more organs of unverifiable bore (ECD, DCD… )

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"When will the transplant social orders, government offices or society all in all understand that we are buried in old ideal models. Attitudinal changes must occur to really build gift of fantastic organs to have an effect on those withering on the holding up rundown" Bromberg and Halloran (AJT 2009; 9: 11-13)

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Living Donor Transplantation – Medicare Guidelines Medicare rules eclipse all the monetary parts of kidney transplantation Pre-privilege versus privilege to Medicare Pre-qualification: a man with end-arrange renal illness who does not yet have Medicare Entitlement: a man who has Medicare eligibility Based on the rules, all pre-transplant administrations for pre-entitled or qualified beneficiaries are charged for the "kidney obtaining" cost focus. Benefactor administrations are then charged to the "beneficiary" transplant focus (administrations before the confirmation for organ acquisition). Taking after confirmation, doctor\'s facility administrations are charged to cost focus and doctor administrations are charged to beneficiary protection.

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Living Donor Transplantation – Medicare Guidelines were composed with the assumption that both the beneficiary and benefactor are housed in similar office. *Internal sets – fits this situation *External sets/chains – don\'t fit! WHAT DO WE DO NEXT? We assessed the Interpretive rules in detail and diagrammed the charging in view of current controls and suppliers of watch over these matched and chain benefactors…

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Current Billing Recommendations for outside Pairs/Chains

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How would we isn\'t that right? Work intimately with YOUR clinical group you have to recognize what they know, when they know it! Work intimately with managerial, budgetary, and contracting groups from included focuses to guarantee letters of understandings set up, protection data is shared, and approvals set up. Decide abilities of your office\'s charging framework to guarantee obscurity of contributor/beneficiary connections. The vast majority of all, have a comical inclination as you work out the coordinations and be glad for YOUR work in lessening the hold up rundown!

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How your OPO can help you Logistical support for organ transportation Arrange all dispatch needs Door-to-entryway benefit Perfusion, bundling and marking bolster Recovering focus in charge of perfusate Supply all bundling and names A facilitator to guarantee adherence to UNOS bundling rules An ABO check page A worksheet archiving all recuperation timing and anatomy.

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What your OPO will require Once the trade is affirmed contact the OPO Be certain you have your UNOS ID and ABO confirmation finish Provide the OPO with the significant information Date/time of methodology Accepting project and contact data Donor Info (UNOS ID, ABO, DOB, and so forth) Provide the OPO with a duplicate of the benefactor outline to bundle with organ

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Suggestions for a fruitful procedure Conference calls with all included gatherings (specialists, organizers, OPO) At slightest one conf call a week earlier Contact between the sending OPO and the OPO of the getting transplant focus Provide a last, composed synopsis of coordinations to all gatherings 24-48hrs preceding case Back-up contemplations

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Suggestions for an effective procedure

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Financial Considerations OPO costs go along to the transplanting focus Minimal bundling costs Minimal staff costs Primarily messenger c

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