1. Immediate Past-President, UNOS Board of Directors
UNOS Update
Stuart Sweet, MD, PhD
Immediate Past-President, UNOS Board of Directors
Region 4
August 25, 2017
In the next minutes, we’re going to talk about:
- strategic planning
- COIIN
- new data reports
- liver

2. OPTN/UNOS Strategic Planning
As we approach the end of the current strategic plan next June, we’re beginning the process of writing a new plan for
We’re building the plan around the same five major goals - more transplants, fair, effective, safe, and efficient
We’re also focused on UNOS’ core competencies – the types of work that UNOS does well, often things that are unique to UNOS.
Match
Data
Quality (examples of each on slide)

3. Brainstorming themes Better matching Focus on improvement
Faster placement, including analysis of historical offer acceptance
Automated decision-making aids (risk/benefit calculator, time to next offer)
Use of behavioral research to improve system interface
Focus on improvement
Peer coaching, effective practice sharing, COIIN
Re-examine outcomes thresholds, including development of long-term outcomes
More data, more easily
APIs, automated connections to EMRs
User-friendly DonorNet and other tools (DonorNet mobile, multi-platform, interface design)
Analysis tools – ROO, RUM, benchmark reports
We started with a brainstorming session at the last board meeting among board members, incoming board members, committee chairs, and UNOS staff leadership
Themes of that brainstorming session were – ON SLIDE

4. Themes--Match More Equity Outcomes Safety Efficiency Match
Automated decision-making tools
Organ transport efficiency
Better placement based on historical data
Revise offer response time policy
National KPD system
Longevity matching for all organs (net benefit)
Re-examine multi-organ allocation policy
Survival risk/benefit calculator
EMR integration to allow for updates on infectious disease results
System enhancements for reporting HLA to improve virtual crossmatching
Streamline policy development and implementation
More effective public comment
Improve diversity on Board and committees
THESE NOTES COVER ALL THREE SLIDES – These slides are a glimpse of a little more detail than the prior “3 themes” slide
Each table brainstormed as a group using a matrix that lists the 5 strategic goals and our three core competencies: match, data, quality.
We had each group fill out their matrix of ideas individually first and then vote for the most impactful ideas, using the guidelines that the idea is aligned, viable, impactful, and measurable.
At the end of the session, we were left with a long list of ideas to refine and discuss further.
In my experience, this matrix is a much better way of wrapping my head around what role we, as UNOS and the OPTN, play in the furtherance of these goals. I’ve heard a lot of people say “why is our #1 goal more transplants? We don’t have the ability to influence that.” But that is not really true if you look at our work in the areas of match, data, and quality and how it might influence this goal. For instance, can we change policies and programming to expedite organ placement? Can we use the data we have from OPOs who increased their volumes and create a forum for sharing this information with other OPOs.

5. Themes--Data More Equity Outcomes Safety Efficiency Data
Utilize behavioral analytics to revise offer system
Develop equity benchmark for all organs
Develop center comparison reports
Collect long-term outcome data
Customize transplant center and OPO specific reports and offer UNOS staff interpretation
Share data on best practices and near misses
EMR integration
Standardize rules for data collection
Each table brainstormed as a group using a matrix that lists the 5 strategic goals and our three core competencies: match, data, quality.
We had each group fill out their matrix of ideas individually first and then vote for the most impactful ideas, using the guidelines that the idea is aligned, viable, impactful, and measurable.
At the end of the session, we were left with a long list of ideas to refine and discuss further.
In my experience, this matrix is a much better way of wrapping my head around what role we, as UNOS and the OPTN, play in the furtherance of these goals. I’ve heard a lot of people say “why is our #1 goal more transplants? We don’t have the ability to influence that.” But that is not really true if you look at our work in the areas of match, data, and quality and how it might influence this goal. For instance, can we change policies and programming to expedite organ placement? Can we use the data we have from OPOs who increased their volumes and create a forum for sharing this information with other OPOs.

6. Themes--Quality More Equity Outcomes Safety Efficiency Quality
Reduce regulatory disincentives
Monitor offer acceptance patterns
Re-examine survival thresholds, use longer-term outcomes
Share best practices from high performing transplant centers and OPOs
Share best practices and near misses
Peer coaching
Revise process for member reviews, actions, and due process
Each table brainstormed as a group using a matrix that lists the 5 strategic goals and our three core competencies: match, data, quality.
We had each group fill out their matrix of ideas individually first and then vote for the most impactful ideas, using the guidelines that the idea is aligned, viable, impactful, and measurable.
At the end of the session, we were left with a long list of ideas to refine and discuss further.
In my experience, this matrix is a much better way of wrapping my head around what role we, as UNOS and the OPTN, play in the furtherance of these goals. I’ve heard a lot of people say “why is our #1 goal more transplants? We don’t have the ability to influence that.” But that is not really true if you look at our work in the areas of match, data, and quality and how it might influence this goal. For instance, can we change policies and programming to expedite organ placement? Can we use the data we have from OPOs who increased their volumes and create a forum for sharing this information with other OPOs.

7. New plan structure Combined OPTN and UNOS plans
Shared high-level goals
Description of current activities
Opportunities for growth
Metrics
So, let’s talk about how we are going to structure the new plan
We will no longer have two plans but one overarching plan that has:
shared, high-level goals (OPTN and UNOS combined)
a description of core activities (so we don’t forget what we do well that we just want to continue doing well – organ center)
opportunities for growth (new initiatives)
And critically, the key metrics we will use to assess whether we are successfully meeting our goal and objectives.

8. Plan Development Calendar
2017
June: Board brainstorming session
July-Oct: Refining/seeking input
November: ExCom/CAC review input/develop rough draft
December: Board weighs in on rough draft
ExCom and CAC finalize for PC
Here’s the timeline for the development of the plan over the course of this Board year:
Across this regional meeting cycle, we will also be presenting major themes and ideas that we have gathered and seek input and feedback from our members.
We are planning for the Executive Committee and the Corporate Affairs Committee to review and finalize a rough draft in November. That rough draft will be presented to the Board for feedback at the December meeting. Following the Board’s feedback, the Executive and CAC will finalize a plan to be distributed for Spring 2018 public comment.

9. Plan Development Calendar
2018
Jan-March: Draft plan out for public comment
April: ExCom/CAC meet in-person, finalize plan
June: Board approves final plan
July: New plan is effective
That plan will be out for comment during the regular PC cycle and presented during the regional meetings.
I don’t know exactly what this will look like at this point, but we also want to engage the staff at the public comment stage, since this input is what the committees will consider as they finalize the plan for presentation to the Board.
Once the public comment period concludes, we will compile the public comments and present those to the ExCom and CAC who will finalize their recommended plan to be presented to the Board at the June 2018 Board meeting.

10. Cohort A Organ Acceptance Rate (50-100% KDPI)
Kick-off and data collection
Waitlist Management
Organ Offer &
Acceptance
We also want to give you an update on the COIIN project, the pilot collaborative project to increase utilization of high and medium KDPI kidneys.
We’re starting to collect early data on the pilot, and the acceptance rates in the pilot hospitals are starting to edge up, though we don’t have enough data to know whether that’s significant or lasting. This is a very data-driven project, and we’ll continue to monitor the outcomes as we make changes and decide how to proceed in the future.

11. COIIN Benefits from Cohort A Teams
“Bringing team together around common goals”
“Collaboration with other centers” and “Hearing the issues discussed with other centers”
“The review of offer acceptance criteria brought a lot of opportunities to our attention”
“Increased awareness by entire team”
“COIIN helped our collaboration with the OPO”
“Transparent data across all participants and contact information for collaboration across centers”
Participating programs have offered positive feedback -

12. Next Steps
Jul 17 –Sep 17
Final 90-day improvement cycle for Cohort A (Care Coordination)
Coaching Visits for Cohort B
Oct 17 – Dec 17
Support for “holding the gains” for Cohort A and continued data updates
Kick-off meeting for Cohort B
First 90-day improvement cycle for Cohort B (Waitlist Management)
And we were able to enroll twice as many programs in the voluntary second cohort just underway. We’ll continue the pilot through the next fiscal year and then analyze the effort to determine the plan going forward.

13. Peds Benchmark Report
I also want to tell you about how we’re continuing to add to automated and self-service data reports:
A new ped tx center benchmark report is now available
Adult only data removed
Comparison groups restricted to under 18
Supplement to standard report on data portal
Reminder that benchmark reports are issued quarterly for all organs
OPO benchmark likely release next spring

14. Recovery and Usage Maps (RUM) Report
Another new report is the Recovery and Usage Map (RUM)
The RUM report visually identifies kidney discards by OPO or TXs by center, within parameters you define using the sliders below . . .
So if you’re a center that specializes in kidneys not always used by the rest of the community, you can see which OPOs might be discarding those organs
Or on the flip side (NEXT SLIDE)

15. Recovery and Usage Maps (RUM) Report
If you’re an OPO having trouble placing kidneys with a specific set of characteristics, you can scan the map to find centers that have taken kidneys like that in the past

16. Data Services Portal
RUM and many other reports are available on the self-serve data services portal

17. Up Next for the Data Portal
Visual living donor follow-up dashboard
Reports to improve data quality
Data submission compliance (CMS and OPTN)
Waiting list management tool for other organs
What else would be helpful? TELL US!
We plan to continue to populate the portal with more automated reports and self-service tools. Let us know what other reports would help you do your work.

18. Liver distribution
Now we’d like to provide a leadership update on the ongoing work of the liver committee on enhancing distribution and reducing geographic inequity

19. External Influence Concerns Liver Committee Consensus 5/8/17
Why Now?
HRSA Interventions
Congress: Appropriations / Statutory Language
Final Rule Critical Comments / Legal Challenges
External Influence Concerns
Set aside 8-District Model
Broader Sharing To Lab MELD Patients
Proximity Circles/Points to Reduce Travel
Liver Committee Consensus 5/8/17
Keeping the December 2016 commitment to bring a proposal to public comment this year
Maintain Momentum
Why are we addressing this issue now?
Over the past year it has been clear that we are facing external challenges to the public/private partnership our community holds to operate the OPTN and direct organ allocation policy. If we are unable to make progress on geographic inequity as directed by the final rule in a way that brings all sides of this debate closer together, we face the risk of interventions from HRSA, Congress (via directive language included in appropriations bills or statutory changes) and the Courts (through legal challenges to the Secretary for failure to address critical comments).
The Liver Committee has made significant progress since the public comment proposal last fall. Based on feedback from the community, they set aside the optimized 8-district model, agreed that, at this point, broader sharing should be directed to patients in need based on lab MELD rather than allocation MELD, and incorporated proximity circles to help reduce the anticipated increase in travel costs associated with broader sharing.
Finally we believe that it is important to keep the commitment we made to our community over the past year to bring a proposal to public comment by the end of this year.

20. Liver Committee Work Plan
Enahancing Distribution
NLRB 
HCC 
Purpose: Revise exception eligibility criteria.
Board Approved: Dec 2016
Purpose: Optimize the distribution system to reduce geographic variation in access to transplant
Public Comment (2): July 31,2017
The Liver committee has been working simultaneously on three parts of the liver system, including establishing a National Liver Review Board (NLRB) to replace the Regional Review Boards, revising the standard eligibility criteria for the largest reason for exception, Hepatocellular Carcinoma (HCC) and making changes to allocation policy to reduce geographic disparity.
The board has approved the first two. With these revisions to the exception system, the MELD/PELD exception scores will more accurately reflect the patient’s disease severity and are the same regardless of geography.
The Committee is bringing forward a proposal to address the final piece, enhancing distribution, in this public comment cycle.
Purpose: Apply exception criteria uniformly.
Board Approved: Jun 2017

21. Enhancing Liver Distribution
Proposing 11-region sharing with 150 mile proximity circle including out of region patients:
5 additional MELD/PELD points to patients within proximity circle
Sequence: Local Status 1A,Peds 1B, Region plus proximity circle
Share to: Adults: lab MELD > 29 Pediatrics: allocation MELD/PELD > 29
DCD and donors > age 70 excluded from this sharing algorithm
(Liver Committee Representative) will present this proposal in detail later today.
Briefly, the committee is proposing…
Key points:
The committee felt that, because of concerns about inequity with exceptions, broader sharing should limited to those with higher lab MELD scores (adults) and children in need of liver transplant based on allocation MELD/PELD
The committee felt that DCD and donors > age 70 should be excluded from broader sharing because of the increased difficulty placing these organs

22. Fall Public Comment
Rationale for moving forward in parallel with additional modeling:
Direction and magnitude of impact on key metrics were consistent across older and newer cohorts.
Proposed solution will share to fewer proximity circle candidates than previous modeling (suggesting the prior modeling is a ceiling)
Sharing using MELD/PELD 29 threshold
Sharing based on lab MELD for adult candidates
Some additional modeling data will become available during public comment period
The committee felt comfortable moving forward with public comment while modeling was in progress because the multiple sets of modeling the committee reviewed indicated that the prior data would be provide a reasonable ceiling for modeling of the current system.

23. Fall Public Comment SRTR Modeling (preliminary results 8/11):
Results similar to prior analyses:
Significant Decrease in Median MELD variance at txp
No change in transport time, increases in % organs flown and transport distance smaller than prior proposals
No change in total transplants or post-transplant mortality. Waiting list mortality rate and totals decrease
Final Report will include impact on vulnerable populations
Will be posted on website and feedback sought (including webinar)
The preliminary results were released on 8/11 and confirm that on a national level, the proposal leads to a significant decrease in variance in median MELD at transplant. Transport time stayed the same and percent of organs flown only increased slightly. The increase in distance traveled is significant but still substantially smaller compared to the other concepts (districts, circles, etc). Total transplants and post transplant mortality are the same. Waiting list mortality rate and totals decrease
The final report will include information about the impact on vulnerable populations will be released by the end of the public comment period. We will circulate the report and post it on the OPTN website. Feedback will be sought, including holding a webinar to share the results.

24. Other OPTN/UNOS Activities
Ongoing Liver Committee Work:
Finalize disparity / impact metrics
Set targets for improvement
Additional policy modifications to meet disparity targets
System Optimization Proposal
Reduce time to access and respond to offers (60 to 30 min)
Limit decision time for primary offers to 60 minutes
Limit number of simultaneous acceptances to two donors
OPO / DSA Performance Metrics
The Committee will continue to work on this effort, including finalizing the disparity and impact metrics to be consider as we evaluate the impact of this proposal, setting targets for improvement and considering additional policy modifications that may need to be implemented if the current proposal doesn’t meet disparity targets.
There is also a public comment document that (OPO Representative) will present today that begins to address some of the logistic issues raised by broader sharing. It includes a proposal to improve efficiency by reducing the time transplant centers have to make decisions and limiting the total number of simultaneous acceptances.
Finally we continue to work on improving metrics to measure OPO performance.

25. Leadership Perspective
Moving Forward
The Status Quo is behind us…
Proposing an incremental, compromise solution
Leadership Perspective
Many similar challenges face the OPTN
This is a test of our public/private partnership
Context
Approach with a system perspective
Contribute to a solution
Our Request
The Status Quo is behind us. The solution being proposed is incremental rather than disruptive and reflects a compromise that addresses in large measure the concerns raised about the prior proposal.
Addressing geographic disparity in liver transplantation is only one of many difficult challenges facing our community. The potential external influences await our ability to demonstrate that we are capable of delivering an effective solution. If we can’t do that, our public/private partnership, which gives our community a large measure of control of organ allocation policy, is at risk.
We ask each of you to approach this proposal from a system perspective - looking beyond your center and DSA as you consider the pros and cons. We will welcome constructive feedback about how this proposal can be improved and monitored to ensure that we reduce geographic inequities without significant unintended consequences.

26. Volunteers are Valuable!!
41,762 Volunteer hours
Average number of hours 1-2 hours per week
Connection to the Transplant community
Meaningful and impactful work
This is really a chance to say thanks, and encourage more folks to volunteer.
Thank you!

27. Immediate Past-President, UNOS Board of Directors
UNOS Update
Stuart Sweet, MD, PhD
Immediate Past-President, UNOS Board of Directors
Region 4
August 25, 2017

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