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Integrity and transplants

November 18, 2005

FOR A LONG TIME, THE BIGGEST issue about organ transplants was how to encourage more people to donate their organs. After all, concerns about fairness, openness and good medical practice seemed secondary to the altruistic mission of giving life to the sick and dying.

Then St. Vincent Medical Center misappropriated a donated liver, transplanting it into a Saudi patient, who ranked 52nd on the regional waiting list, instead of its own patient, who was at the top of the list -- and who subsequently died. The liver program was closed down, but people's faith in the fairness of the transplant system was rattled. The new revelations by Times reporters about UC Irvine Medical Center's liver transplant program -- the second Southern California program to close within a week -- lays bare more systemic problems.

Various agencies that oversee these programs have different rules. If a hospital isn't meeting certain requirements, or is under investigation, these agencies often don't tell each other -- and no one tells the patients. The system sorely needs coherence, closer oversight and strict rules about operations and patient information.

UCI has turned down livers for transplant at two to three times the rate of other hospitals. Regardless of whether such decisions were justified, they look bad in light of UCI's low numbers of liver transplants each year for the last several years, its failure to keep a full-time transplant surgeon on board and its low one-year survival rate. All three of those fail to meet federal standards. Yet the federal funding agency didn't even review the problems until it received a complaint from a UCI patient.

Nor did the United Network for Organ Sharing, the nonprofit group that certifies transplant centers. (It was a network audit that led to the St. Vincent discoveries.) In the case of UCI, the network launched a review in June, but patients were never told about it. Nor did the network contact U.S. or state regulators.

To make matters more confusing, the federal Center for Medicare Management requires centers to do a minimum number of transplants a year -- 12, in the case of livers. UCI did eight a year from 2002 to 2004, and five this year. But the network doesn't have similar requirements for centers; instead, it requires the doctors to perform a certain number a year. The state has yet different rules.

The stakes are too high for this patchwork system to go forward without reform. As soon as a hospital's programs fall short under any of these monitors, it should be required to notify its patients. Information-sharing among agencies and regular enforcement should be standard. Just as important, patients must be told, openly and regularly, the requirements of the various agencies and whether their healthcare providers meet them.

Of course, it makes sense for any patient who confronts a perilous health problem to get second and third opinions. Patients should ask how many procedures are done each year by both the center and the doctor, and what the success and survival rates are. UCI, ironically, gives its new patients a booklet that suggests they ask some of these questions.

Transplant patients are frail, frequently tired and struggling emotionally. They often lack the time and energy to look up data. They shouldn't have to police the doctors and hospitals providing care. Yet The Times' reports revealed that federal officials rely on transplant centers to report their own problems.

UCI has had its own history of problems with proper oversight dating from at least a decade ago. The medical center's chief, Dr. Ralph Cygan, made it a priority to build the hospital into a premier research and cutting-edge medical institution. That's a worthy goal, but with Cygan on administrative leave over the miscues on liver transplants, UCI should focus on the medical basics: integrity.

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