What Number Are We? Groupthink and the Donor Heart Offer Freefall

Abstract

t is 11 pm and your heart transplant coordinator calls with yet another heart offer.Instead of formally presenting objective donor data, the coordinator remarks, "We are number 199 for this heart offer and every other center has turned it down for quality.Should I continue to evaluate this donor?"In this month's issue of Circulation: Heart Failure, Baran et al 1 hypothesize that knowledge of the donor sequence number (DSN)-the allocation order of a potential recipient for a given organ offer-may discourage programs from accepting offers.Put another way, groupthink may decrease the desirability index of a particular heart offer, and as a result, the middle of the night heuristic on which we rely to efficiently field offers may not be in the best interest of our patients and may unnecessarily result in donor heart offer freefall.The authors retrospectively review United Network for Organ Sharing data from 12 363 heart donors after 2007 (through 2014) when the new electronic Donor-Net program made DSN available to transplant centers.Overall, Baran et al 1 found that 58.3% of donors were allocated locally, with most (93.8%)allocated within 500 miles.The median DSN was 3, with 91.1% of offers accepted within the first 30 DSNs.DSNs were divided into 10 groups, each representing 5 DSN (group 1=DSN 1-5, group 2=DSN 6-10, etc).Higher DSN recipients were older, farther from the donor, and had longer associated ischemic times.In addition, donors matched to higher DSN recipients were more likely to be sex mismatched (female donor to male recipient), have lower ejection fraction, and to be categorized as increased Public Health Service Risk.Donors allocated in DSN group 1 were typically local and <100 miles away from recipient hospital compared with the other DSN groups, where distance to the donor hospital was >200 miles and increased with DSN group.It is notable that distance to donor hospital was within 500 miles, even among DSN group 10.The authors conclude that DSN does not negatively impact survival (P<0.09), that is, recipients fare similarly whether the DSN is 5 or 50, and suggest that even at higher DSN-up to 400-there is no difference in survival; however, these data are not shown.Unfortunately, it would be challenging to accept the conclusions of the survival analysis due to its significant limitations.The study is underpowered with only 0.6% of recipients in DSN group 10 and only 2% with a DSN >100.In addition, the authors did not adjust for transplant-related variables and for a variety of clinically relevant recipient characteristics, such as VAD status, status at time of transplant, and acuity.By only considering donor characteristics, the authors erroneously assume that the recipients at high and low DSNs are the same.A donor is offered first to the highest priority candidate.Therefore, as the sequence progresses, candidates decrease in priority and are presumably less acutely ill, factors