Susan L. Orloff, MD, FAASLD, believes that it is time to re-evaluate how quality after liver transplantation is defined.
“Adhering to externally imposed metrics can stunt innovation and creativity due to risk-averse behaviors and sticking to the status quo,” said Dr. Orloff, Professor of Surgery and Chief of the Division of Abdominal Organ Transplantation/Hepatobiliary Surgery at Oregon Health & Science University.
During the Sunday’s Thomas E. Starzl Transplant Surgery State-of-the-Art Lecture “Zen and the Art of Liver Transplantation Quality,” Dr. Orloff discussed the elusive concept of quality for liver transplantation, and outlined three areas of focus for innovation within the field.
In the health care system, quality is currently everywhere and can be defined using a wide variety of metrics including low cost, low mortality rates, access to care, low waitlist death rates, functionality, or patient satisfaction. There is quality that matters to the patient, to the provider, to the health system, and to governmental oversight agencies.
Dr. Orloff surveyed 100 friends and colleagues about the definition of quality in liver transplantation, and responses ranged from objective (added life expectancy) to the romantic (freedom through transformation of health). Dr. Orloff also asked Thomas Starzl, MD, PhD, FAASLD, how he defines quality and he responded: “Quality is defined by quality of life after liver transplantation – this is inversely related to the amount of immunosuppression one has to take. If one is not off of immunosuppression, you walk in the shadowy world of infection, de novo malignancies, and cardiovascular disease, which prevents long life.”
Ultimately, by trying to define quality, the field is trying to objectively measure something that is subjective, Dr. Orloff said. She encouraged attendees to collaborate to create a future path of improvement of quality on all fronts through innovation.
The first area of innovation for liver transplant requires an examination of how to get more organs. Dr. Orloff listed many possible ways to obtain more organs including acceptance of expanded criteria donors, donation after cardiac death, or the increased use of split livers. The highest potential for expansion of liver donation is through increased use of living donors.
In addition to obtaining more organs, clinicians should look for ways to prevent the “wasting” of available organs. Strategies to prevent waste could include things like avoiding futile transplants, conducting donor intervention research, changing standards for what constitutes a usable organ, becoming less risk averse, and examining the use of machine perfusion strategies.
According to Dr. Orloff, a final area for innovation in liver transplant is optimizing the organs that are available to patients. For example, the use of normothermic machine perfusion (NMP) has great promise for expanding the donor liver pool and improving donation after cardiac death outcomes.
It may be possible to achieve all three of these goals through the use of deceased donor intervention research. “Donor intervention research has the potential to increase the quantity and quality of organs available for transplant from deceased donors,” Dr. Orloff said.
At the conclusion of her lecture, Dr. Orloff acknowledged that it was likely that she did not ever fully define what quality in liver transplantation means. Quality is for each person to decide, she said.
However, she did discuss what she felt was an example of quality after liver transplantation. She showed pictures of a former transplant patient who is the only Federal Aviation Administration-approved pilot who has had a liver transplant. Transplanted in 1997, he is still gainfully employed, flying, happy, and very fulfilled, she said.
“We as physicians, surgeons, and health care workers are the stewards of donated gifts – organs – and our patients’ care,” Dr. Orloff said. “We must continue on this magical and privileged path to seek the means to make a better world for all of our patients through innovation, creativity, setting new metrics, taking some risks – so that as a collective body we may achieve our patients’ freedom from the shackles of disease through transformation of health.”