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The Authors’ Reply

Massie, Allan, B., PhD, MHS1,2; Roberts, John, P., MD3

doi: 10.1097/TP.0000000000002109

1 Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.

2 Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.

3 Department of Surgery, University of California, San Francisco, CA.

Received 27 December 2017. Revision received 11 January 2018.

Accepted 15 January 2018.

The authors declare no funding or conflicts of interest.

Correspondence: John P. Roberts, MD, Box 0780 505 Parnassus San Francisco, CA 94143-0780. (

Dear Editors,

We appreciate the interest that Goldberg et al1 have in our editorial. We would like to respond to a few of their points.

In regard to the level of spending on increasing organ donation, we are sorry to say that it appears that we have underestimated the spending on public education for organ donation by 2 orders of magnitude. In addition to the millions spent on the collaborative, each of the 58 organ procurement organizations has a substantial portion of the budget dedicated to increasing organ donation in the local area. These expenses include public education, physician education, hospital outreach, and administration of these services. For example, 1 organ procurement organization (OPO) in Texas, LifeGift reported 2.6 million in public and professional education expenses in 2015,2 whereas another in New York, Liveon NY reported 3.3 million in 2015.3 If the 56 other OPOs are spending similar amounts, our estimate of “tens of millions” would underestimate the potential spend of 1 billion dollars over 10 years. In any case, there is no clear path to improving organ donation in the United States as these large spends have not made major changes in donation rates. Even for countries that have touted improvements in donation, these improvements are usually from increased utilization of older donors.4

The authors argue that there is substantial untapped potential in organ donation in the United States, a statement that we agree with. While the authors focus on large potential increases in a few metropolitan donor service area (DSA)/OPOs, their data suggest that almost every OPO has untapped potential; but as mentioned above, the mechanism to increase donation is not clear as it appears that the huge amounts of money spent on public awareness has not moved the needle. The authors correctly point out that donation rates are driven not just by DSA/OPOs but by a complex interplay between patients, healthcare providers, policymakers, and the broader community across the entire DSA. Indeed, the complexity of the system suggests that DSA/OPOs alone cannot be responsible for geographic disparities in donation. This may explain why geographic disparities have persisted over decades. Patients in DSA/OPOs with lower liver availability cannot wait on the possibility that their community may one day discover the key to dramatic increases in local donation.

It has recently become clear that the transplant community has delayed too long in meeting the requirements of the Final Rule; the courts are rectifying our inability to act by removing the DSA/OPO as the unit of distribution for lung transplantation. The courts, unlike Goldberg et al, do not see the DSA/OPO as a reasonable unit of distribution. Although the recent change in liver distribution passed by the Organ Procurement and Transplantation Network board may prevent legal action to expand liver distribution beyond the DSA, the retention of the DSA as a unit of distribution in the new policy may be challenged.

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1. Goldberg DS, Shafer T, Siminoff L. Important facts about organ donation and OPO performance. Transplantation. 2018;102:e249–e250.
2. Nonprofit Explorer: Research Tax-Exempt Organizations. ProPublica. Published September 15, 2017. Accessed January 4, 2018.
3. GuideStar USA. GuideStar Nonprofit Report: LiveOnNY, Inc. Accessed January 4, 2018.
4. Halldorson J, Roberts JP. Decadal analysis of deceased organ donation in Spain and the United States linking an increased donation rate and the utilization of older donors. Liver Transpl. 2013;19:981–986.
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