Economic rewards to motivate blood donations, by Lacetera, Macis and Slonim

This just out in Science: Economic rewards to motivate blood donations. It suggests that old conclusions need to be revisited based on new evidence.

"The position and guidelines of the World Health Organization (WHO) and several national blood collection agencies for nearly 40 years have been based on the view that offering economic incentives to blood donors is detrimental to the quantity and safety of the blood supply (1). The guidelines suggest that blood should be obtained from unpaid volunteers only (2). However, whether economic incentives positively or negatively affect blood donations (and other prosocial activities) has remained the subject of debate since the positions were established (2–8).

"Evidence consistent with the WHO position came originally from uncontrolled studies using nonrandom samples and, subsequently, from surveys and laboratory studies indicating that economic incentives can “crowd out” (decrease) intrinsic motivations to donate and can attract “worse” donors (9). This evidence arguably affected policies, such as bans on compensation for blood and organ donations in many countries.
...
"With a few early exceptions based on small, nonrepresentative samples (12), field trial evidence on how economic incentives affect blood donations has been absent. But field-based evidence from large, representative samples has recently emerged. The results are clear and, on important questions, opposite to the uncontrolled studies, surveys, and laboratory evidence preceding them."
...
"Conclusion

"In light of the recent evidence, it is time to re-examine policy guidelines for increasing and smoothing blood supply, including whether incentives can play a role. There are efforts under way from different parts of society toward using rewards to increase donations. The U.S. 9th Circuit Court of Appeals' 2012 ruling legalizing compensation for bone marrow donations through apheresis was initiated by private individuals (32). A company prompted a 2010 European Court of Justice ruling that allowed importation of blood products obtained from compensated donors (33). Researchers and clinicians have noted that some WHO guidelines (e.g., emphasis on exclusive use of nonremunerated donors and centralizing blood collection organizations) are unintentionally adversely affecting blood collection in sub-Saharan Africa (34).

"In addition to economic incentives, policy-makers should consider nonpecuniary rewards (e.g., symbolic and with social recognition) and various appeals. Debates on ethical issues around giving rewards for donations (35) should be encouraged. But there should be little debate that the most relevant empirical evidence shows positive effects of offering economic rewards on donations."

Same sex marriage in Latin America

Things are changing all over the Americas regarding this no longer so repugnant transaction: How Latin Culture Got More Gay

"BRAZIL is potentially poised to become the third and largest country in Latin America to legalize same-sex marriage, following a judicial order on Tuesday. Argentina was the first, in 2010, after the government brushed aside objections from Cardinal Jorge Bergoglio of Buenos Aires, now the pope. The Uruguayan legislature followed suit last month. Mexico City has allowed such unions since 2010, and the Mexican state of Quintana Roo since 2011.
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"These developments not only undermine stereotypes about machismo, but also the assumption that the prominence of Catholicism makes progressive change impossible. Same-sex marriage is legal in Belgium, Portugal and Spain, and Ireland recognizes civil unions. As the United States Supreme Court debates same-sex marriage, perhaps it should consider the precedent set by other nations of the Western Hemisphere."

Deceased donor waiting lists in Germany: scandal and aftermath

In an article entitled "Trust is Everything," Sue Pondrom reports in the American Journal of Transplantation (May 2013, vol 13 issue 5 pp1115-6) on the aftermath of a German transplant scandal.

"After a scandal regarding transplant corruption in Germany, the Deutsche Stiftung Organ transplantation (DSO), Germany's organ procurement organization, has announced that organ donations in the country were down nearly 13% by the end of last year.

"Public confidence in Germany's transplant system has suffered dramatically since newspapers throughout the country described cases of waitlist manipulation over the last 10 years at four liver transplant centers: University of Göttingen, University of Regensburg, Munich Klinikum rechts der Isar hospital and University Hospital Leipzig. At all four centers, doctors falsified liver patient medical records to indicate the patients were also undergoing dialysis. As a result, those patients were erroneously moved up the waiting list."

Post ATC post

Well, I'm back from the American Transplant Congress in Seattle, and it was quite nice to see multiple sessions on various aspects of kidney exchange, which has now graduated to the status of one of the standard ways of arranging kidney transplantation.

Here's the ATC's coverage of my Sunday talk: Keynote: Medical Community, Economist Collaboration Essential in Kidney Exchange

Alvin E. Roth, PhD: ‘Economics is about more than money and prices. It's also about organization, cooperation and coordination.'

If ever an endeavor existed that calls for careful, thoughtful collaboration, it is paired kidney exchange. Nobel laureate economist Alvin E. Roth, PhD, addressed the challenges in such exchanges and what economists can bring to this collaboration when he delivered Sunday's Keynote Lecture, "Kidney Exchange: An Economist's Perspective."

"Many things must happen to bring kidney transplant donors and recipients into the operating room," said Dr. Roth, the Craig and Susan McCaw Professor of Economics at Stanford University and the George Gund Professor Emeritus at Harvard University. "For some of those things, it has proven beneficial to look beyond the boundaries of the medical community to economists and market designers. Economics is about more than money and prices. It's also about organization, cooperation and coordination. 

Interdisciplinary collaboration is common in market design because market designers help experts in specific areas organize to achieve their goals. Dr. Roth said some remarkable transplant surgeons have collaborated with him and his colleagues in the ongoing effort to increase transplantation through exchange.

Even more collaboration will be required to coordinate among the multiple organizations involved in kidney exchange. A collaborative system that encompasses the largest pool of patients theoretically would produce the most transplants, but large organizations can be bureaucratic and inhibit innovation if not properly structured, he said. Some of the fastest-moving, entrepreneurial, innovative transplant organizations have been arranging the most transplants.

"Collaboration among kidney exchange programs is going to be important," Dr. Roth said. "However, we will have to put some careful thought in how to do it." 

In discussing logistics, he praised the non-directed, non-simultaneous donor chain as an innovation that has allowed the exchange of more kidney donations and has led to an increasing number of transplants. The chain begins with a non-directed donor, i.e. one who does not have an intended recipient and who donates to a patient in the kidney exchange pool of patient-donor pairs. That patient's donor continues the chain by donating to another patient in the pool, and so on, typically ending in a donation to a patient who has no donor.

"The ability to make non-simultaneous donations has allowed these chains to become quite long," Dr. Roth said. "That, in turn, has produced many more kidney transplants, which can include more of the most highly sensitized patients."

As more transplant centers have become adept at kidney exchange, there is a growing tendency for them to hold back their easy-to-match patients from the centralized kidney exchange pools to match these patients in their own centers. The consequence has been that hard-to-match patients are overly represented in kidney exchange pools.

"Easy-to-match patients in the mix are good for hard-to-match patients," Dr. Roth said. "We need to find ways to make it reasonable for the easy-to-match pairs to be in the large kidney exchange pools."

Finance also is an issue. Kidney exchange involves collaboration among hospitals, each of which may have different charges for nephrectomies, for example. One solution may involve developing a standard acquisition charge to make live kidney donation as uniform as it already is for deceased donor kidneys.

And expect kidney exchange design to remain in flux.

"The design of how kidney exchanges are organized is an ongoing process that has to change in reaction to changes in how transplant centers behave and what the patient pool looks like," Dr. Roth said. "We shouldn't think of it as something that is fixed in time but something that requires constant attention." 

5 Are Convicted in Kosovo Organ Trafficking

Here's the story from the NY Times: 5 Are Convicted in Kosovo Organ Trafficking

"Five people were convicted Monday in Pristina, the capital of Kosovo, in connection with an elaborate organ-trafficking network that lured poor people to the country to sell their kidneys and other organs to wealthy transplant recipients from Israel, the United States, Canada and Germany. Organs sold for as much as $130,000 each.
"The defendants, all Kosovars, were tried before a panel of two European Union judges and one Kosovar judge. A special prosecutor for the union, Jonathan Ratel, called the case a landmark because doctors had been convicted.
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“The sole and driving motive for this exploitation of the poor and the indigent was the opportunity for obscene profit and human greed,” Mr. Ratel, the prosecutor, said Monday. “In every sense this was a cruel harvest of the poor.”
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"According to the indictment in the case, traffickers in the network promised payments of up to $26,000 to poor people in Turkey, Moldova and Russia to persuade them to travel to Kosovo and donate an organ. They were asked to sign false documents saying they were donating to a relative for humanitarian reasons.

"Two dozen donors were taken in by the scheme; many were never given any compensation and were released without adequate medical care."
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"Mr. Ratel said the Dervishis were aided by Dr. Yusuf Sonmez, whom he called a notorious international organ trafficker. Dr. Sonmez is a fugitive and may be in South Africa, Mr. Ratel said."

An economist goes to a surgery conference: American Transplant Congress, May 18-22

An unusual thing about giving a talk at a transplant conference is that it comes with a series of pre- (and perhaps post-) announcements...not that I'm feeling any pressure...

Don't Miss featured Keynote Speaker & Nobel laureate Alvin E. Roth, PhD, presenting

"Kidney Exchange: An Economist's Perspective" 
Sunday, May 19, 5:45 - 6:15 pm

With decades of experience and knowledge in experimental economics, game theory, and market design, Dr. Roth will provide insight into how he has applied economic theory to real-world problems at this year's ATC meeting.

Dr. Roth serves as the Craig and Susan McCaw Professor of Economics at Stanford University and the George Gund Professor of Economics and Business Administration Emeritus at Harvard University. He contributed to the National Bureau of Economic Research paper on kidney exchange, which was published in the Quarterly Journal of Economics.

Dr. Roth was awarded the Nobel Memorial Prize in Economic Sciences jointly with Lloyd Shapley for his work on the theory of stable allocations.

View More Program Highlights

Here's an ATC press release:

Nobel Laureate to Describe How Economics Play Key Role in Kidney Exchange

Nobel laureate Alvin E. Roth, PhD, will discuss the economics of kidney exchange when he delivers the Keynote Lecture.

Nobel laureate Alvin E. Roth, PhD, has applied his economics expertise to strategies for organizing paired kidney donation exchange effectively, and he will share insights he has gained from this work when he presents the Keynote Lecture "Kidney Exchange: An Economist's Perspective" Sunday evening, May 19.

"This lecture will be an opportunity to offer an economist's perspective to a community of clinicians, surgeons and other health professionals, and explain what I see as some of the issues involved in implementing kidney exchange effectively," he said. "As an economist, I study how exchanges can be organized, and there is a great deal that has been, and can be, done to help organize kidney exchange."

The issues of organization emerge at different levels — within a transplant center, within a kidney exchange network, in collaboration among kidney exchange networks and in the development of national policy for kidney exchange. While much of the conversation focuses on what kinds of kidneys are suitable for the different patients needing transplantation, Dr. Roth said, attention also needs to be paid to how to make kidney exchange work well for transplant centers so that it can continue to grow.

Dr. Roth comes to the lecture with decades of contributions in game theory, market design and experimental economics, and in applying economic theory to solutions for real-world problems. He ventured into the real-world problem of kidney exchange when he and economist colleagues wrote a National Bureau of Economic Research paper "Kidney Exchange," which was ultimately published in the May 2, 2004, edition of the Quarterly Journal of Economics. They corresponded with transplant surgeon luminary Francis L. Delmonico, MD, and immunologist Susan L. Saidman, PhD, of Massachusetts General Hospital, Boston, and ultimately collaborated in forming the New England Program for Kidney Exchange (NEPKE) in 2005. Dr. Roth also worked with transplant surgeon E. Steve Woodle, MD, urologist Michael A. Rees, MD, and colleagues in developing the Paired Donation Consortium in Ohio and the Alliance for Paired Donation.

Currently, Dr. Roth is the Craig and Susan McCaw Professor of Economics at Stanford University and the George Gund Professor of Economics and Business Administration Emeritus at Harvard University. He was awarded the Nobel Memorial Prize in Economic Sciences jointly with Lloyd Shapley for his work on the theory of stable allocations and the practice of market design.

and here's the ATC pre-talk post this morning (now I better finish preparing the talk...)

Transplant surgeons and economists are joining forces to implement efficient, effective paired kidney donation exchange systems. Learn how economics plays a role in this endeavor when Nobel laureate Alvin E. Roth, PhD, speaks about "Kidney Exchange: An Economist's Perspective" during the Keynote Lecture at 5:45 pm today in Room 6E. He won the Nobel Memorial Prize in Economic Sciences jointly with Lloyd Shapley, PhD, in 2012 for his work on the theory of stable allocations and the practice of market design. 

"Organized kidney exchange clearinghouses arose out of collaborations between transplant professionals interested in improving patient care by expanding the number of transplants, and economists interested in market design. Transplant institutions have their different interests and ways of looking at patient care, and treating people with end-stage renal disease is a multi-billion dollar industry in the United States, so it's not surprising to find that sometimes complicated economic interests are also at play," said Dr. Roth, the Craig and Susan McCaw Professor of Economics at Stanford University and the George Gund Professor of Economics and Business Administration Emeritus at Harvard University. 

Exploring how those economic and medical institution interests can interact will help all parties involved determine how to move forward, Dr. Roth said. Kidney exchange will require innovations in how to arrange, coordinate and conduct surgeries, and in how to assemble and organize efficient clearinghouses. Therefore, paired kidney exchange is a natural area of collaboration between surgeons and economists. 

Issues of organization entail the various levels of kidney exchange, he noted. Within a single transplant center, the question is how to organize surgeries to obtain the most suitable transplants for the most patients. At the next level, there is the question of how different transplant centers can coordinate with one another in a kidney exchange network. And then there are questions about how different kidney exchange networks function and interact with each other. Thus questions about organizing kidney exchange nationally are often at least partly about economics. 

A recent challenge is that many transplant centers now have enough experience with kidney exchange to conduct their own exchanges internally among their patient-donor pairs. The unintended result, Dr. Roth said, is that kidney exchange pools now consist increasingly of highly sensitized patients. One response to an over-representation of highly sensitized patients is the development of long non-simultaneous, non-directed donor chains to match compatible kidneys for these patients. 

"We have to figure out ways to get more of the easy-to-match pairs into pools where they can be matched with harder-to-match pairs," he said. "Suppose you have many highly sensitized patients, and when you find a compatible kidney from an incompatible pair that would work for another pair, it's unlikely the receiving pair can donate a kidney back. That's why chains are particularly important for highly sensitized patients. Long non-directed donor chains are beneficial to the most highly sensitized patients. Transplant centers can exchange paired kidney donations on a national level and still perform the surgeries in their own centers." 

What can transplant surgeons, clinicians and allied health professionals do? Attend Dr. Roth's lecture, understand the benefits of kidney exchange and contribute to growing it. Transplant professionals and economists alike are still working out how to make kidney exchange work well for patients, donors and transplant centers. 

"Working those things out will make it easier for transplant centers to enroll their patients and donors," Dr. Roth said. "There are gains to achieve through collaboration among transplant professionals with different kinds of expertise. It is a great privilege as an economist to be able to contribute to this endeavor. It is good that transplant professionals interested in kidney exchange have been able to look outside of what is known just in the surgical community to bring in other kinds of help. It is good for us as economists that we are able to obtain these insights from surgical experts so that we can assist them."

An Alliance for Paired Donation reception: "Business Attire"

I got the following invitation by email: I assume that the photograph is to illustrate what is meant by "Business Attire" (so surgeouns won't come in scrubs...)

Join us in honoring our esteemed colleague,   Alvin Roth, PhD,   winner of the 2012 Nobel Prize in Economics During the ATC Meeting Saturday Evening, May 18th in the Willow Room At the Sheraton Seattle Hotel 1400 Sixth Avenue, Seattle, WA 98101 Time: 6:00 - 8:00 p.m. Business Attire Please RSVP By May 7th 2013 to reserve your seat l-r, Alvin Roth, PhD, with King Carl Gustaf XVI of Sweden at the Nobel Prize Ceremony

.Among Dr. Roth's achievements, the Nobel Prize Committee cited his work with the Alliance for Paired Donation (APD) in developing the algorithms that are used in the APD and other kidney paired exchange programs. After drinks and  hors d'hoeuvres, there will be a short presentation by Dr. Roth and  by Dr. Alan Leichtman, co-investigator of the Alliance for Paired Donation's Agency for Healthcare Research and Quality (AHRQ) sponsored study to propose a standard acquisition cost (SAC) for kidney donors who donate through the mechanism of kidney paired donation.