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The liver transplant team at University of Colorado Health Sciences Center and its sociological significance

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Title:
The liver transplant team at University of Colorado Health Sciences Center and its sociological significance
Creator:
McQuillan, Eileen V
Publication Date:
Language:
English
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x, 129 leaves : ; 28 cm

Subjects

Subjects / Keywords:
Liver -- Transplantation -- History -- Colorado ( lcsh )
Transplantation of organs, tissues, etc -- Social aspects -- Colorado ( lcsh )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Bibliography:
Includes bibliographical references (leaves 128-129).
General Note:
Department of Sociology
Statement of Responsibility:
by Eileen V. McQuillan.

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Source Institution:
|University of Colorado Denver
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|Auraria Library
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
181588436 ( OCLC )
ocn181588436
Classification:
LD1193.L66 2007m M36 ( lcc )

Full Text
/
THE LIVER TRANSPLANT TEAM
AT UNIVERSITY OF COLORADO HEALTH SCIENCES CENTER
AND
ITS SOCIOLOGICAL SIGNIFICANCE
by
Eileen V. McQuillan
B.A., Metropolitan State College, 1988
A thesis submitted to the
University of Colorado at Denver and Health Sciences Center
in partial fulfillment
of the requirements for the degree of
Master of Arts
Sociology
2007


by Eileen V. McQuillan
All rights reserved


This thesis for the Master of Arts
degree by
Eileen V. McQuillan
has been approved
by
l/lkloi
Date
Andrea Haar


McQuillan, Eileen V. (M.A., Sociology)
The Liver Transplant Team at University of Colorado Health Sciences Center and its
Sociological Significance
Thesis directed by Associate Professor Can dan Duran-Aydintug
ABSTRACT
The Liver Transplant Team at the University of Colorado Health Sciences Center
was examined using both individualized interviews of the major team members and
observation of its processes over the past twelve years. These individuals are involved in
all aspects of patient care from the diagnosis and treatment of end-stage liver disease
through to evaluation and listing for transplantation, and the on-going, lifelong post
transplant care that begins after discharge from die hospital after transplantation. Aspects
of patient care as well as details of listing, organ allocation, and financial concerns are
addressed. Pertinent sociological frameworks are reviewed and their relevance to the
liver transplant world discussed.
The complexity of transplantation along with the sociological and medical
ramifications of transplantation for society and for individual patients and families makes
it a fertile topic for further study. Examination of the role of ancillary professional
personnel (such as radiologists and pathologists), all of whom are critical to die success
of a transplant program, is an area that deserves further study.
This abstract accurately represents the content of the candidates thesis. I recommend its
publication.
Signed
Candan Duran-Aydintug


DEDICATION
Dedicated to the memory of Steve McQuillan (my son), Ernest and Irene Jones (my
parents), and Geraldine Urban (my friend) all gone but never forgotten.


ACKNOWLEDGMENT
With heartfelt thanks to my professor, mentor and friend, Dr. Can dan Duran-Aydintug,
without whom this project would have been neither attempted nor completed and to Dr.
Leigh Ingram and Andrea Haar for their time and energy in serving on my committee.
Thanks also to the members of the Liver Transplant Team who so generously shared their
time, thoughts and concerns with me and patiently answered my many questions. To my
son, Jeff, and friends Cathy Christopher and Judie Foster who agreed to read and comment
on the project thank you for time and effort Thanks also to the many friends whose
support and encouragement kept me going. Finally, to my friend Geraldine Urban, now
passed on, who sparked my interest in pursuing a Masters Degree in Sociology, and
whose example was and continues to be an inspiration to all who knew her.


TABLE OF CONTENTS
LIST OF TABLES...........................................................x
CHAPTER
1. THE WORLD OF LIVER TRANSPLANT
UNIVERSITY OF COLORADO HEALTH SCIENCES CENTER... 1
2. THE LIVER TRANSPLANT TEAM
Igal Kam, MD........................................4
James F. Trotter, MD................................6
Tracy Steinberg, BSN, MSN, CCTC.....................7
Catherine Ray, BSN, MA..............................9
Mary McClure, BSN..................................10
Lana Schoch, BSN...................................12
Michelle Miller, BSN...............................12
Michael Talamantes, MSW, LCSW......................13
Tim Brackett, BSN, JD..............................14
The Transplant Database............................15
Weekly Multi-disciplinary Meetings.................17
The Liver Support Group............................20
Jane Biglin, MBA...................................20
Eileen McQuillan, BA............................. 22
Patty Polsky, MBA..................................23
vii


3.
THE PROCESS OF LIVER TRANSPLANT
The Roots of Liver Transplant in Colorado............25
United Network for Organ Sharing (UNOS) and the Organ
Procurement and Transplantation Network (OPTN)........27
Model for End Stage Liver Disease (MELD); Pediatric
Model for End Stage Liver Disease (PELD).............30
Evaluation and Listing for Transplant.................34
The Importance of Social Support......................42
We have a donor!....................................43
Organ Procurement Organization (OPO)..................45
The Surgery...........................................48
Recovery and Discharge................................51
Clinical Follow-up....................................53
Post Liver Transplant Treatment Issues................58
Outcomes..............................................61
4. PROBLEMS TO BE SOLVED
Increasing the Donor Pool............................64
Living Donor Liver Transplant........................68
Paying for Liver Transplant...........................75
Institutional Issues.................................81
Ethical Considerations...............................84
Involvement of Drug Companies in Transplantation......88
If we could change the Transplant Team...............89
5. SOCIOLOGY AND THE LIVER TRANSPLANT TEAM
Introduction.........................................92
The Medical Model....................................93
vm


Social Construction of Reality............................95
The Social Construction of Illness........................97
Functionalism............................................100
The Sick Role, Stigma and Deviance.......................101
Symbolic Interaction.....................................106
Conflict.................................................107
Reification..............................................109
Modernization and Rationalization........................110
Dramaturgical Analysis...................................112
Ideology.................................................115
6. SUMMARY
Final Thoughts from a Member of the Liver
Transplant Team............................121
APPENDIX
A. GLOSSARY OF TERMS.............................123
REFERENCES
128


LIST OF TABLES
Table
2.1 Transplant team weekly meetings......................................18
3.1 Liver transplant team outcomes.......................................62
x


CHAPTER 1
THE WORLD OF LIVER TRANSPLANT
UNIVERSITY OF COLORADO HEALTH SCIENCES CENTER
The Liver Transplant Team at the University of Colorado Health Sciences
Center, Denver, Colorado, is an example of a multi-disciplinary, collaborative effort to
care for liver transplant patients, both before and after transplant surgery. It is composed
of physicians (hepatologists) and transplant surgeons, transplant coordinators and nurses,
social workers, and numerous administrative support personnel, each playing a specified
role in the effort. In addition, specialized transplant services require the skills of
endoscopists, body radiologists, interventional radiologists, and pathologists, all of whom
are experienced in the diagnosis and treatment of liver transplant patients. In the clinical
setting, the services of medical assistants and phlebotomises are required. Hepatologists
rotate through out-patient clinic services and in-patient services. Surgeons rotate as well,
in a slightly different fashion. Hepatology nurses care for pre-transplant patients.
Transplant Coordinators, who care for post liver transplant patients, are on call in the
evenings and weekends, as are social workers. The activity of these individuals is
orchestrated such that patients have access to providers around the clock, 36S days a year.
When a difficult case presents, each available member of the team is consulted,
assesses the relevant data, and offers an opinion. Discussion ensues. The more
complicated the case, the more difficult the process of finding consensus. Physicians and
surgeons differ in their approach to such cases. When there is a difference of opinion,
1


however, physicians defer to surgeons on surgical matters, and surgeons defer to
physicians on medical matters. Each group respects the other groups opinion and
decision. That is not to say that there are never conflicts or disagreements. The
disagreements must be resolved, however, because in the end what matters is the
patients well-being. Everyones goal is to provide the best possible outcome for each
patient.
Such collaborative decision-making is remarkable to witness. In a world as
complex as the transplant world, a world that changes almost daily, a world where new
information is available at ever faster rates, a world in which error means that a patient is
harmed, the functioning of this group of professionals known as The Liver Transplant
Team is impressive and inspiring. These are serious people who daily deal with very
serious, life and death, matters who can, at the same time, socialize with one another and
laugh together easily. The Team is very good at maintaining balance and its skill at this
may be an essential ingredient of its success.
The purpose of this project is to describe the workings of the liver transplant
world and its occupants at the University of Colorado (The Liver Transplant Team) and
to correlate their activity with sociological theory. Representatives from each core
subgroup have been interviewed. A narrative on each interviewee will be provided
including a description of their professional history and their role within the group.
Discussion follows on various key issues that comprise the facets of liver transplant
including information gleaned from both the interviews and observations by the author
2


(who is also a member of the Team). Finally, various sociological theories will be
discussed in the context of liver transplantation.
3


CHAPTER 2
THE LIVER TRANSPLANT TEAM
Igal Kam, M.D., Professor of Surgery, Chief of Transplant Surgery
Dr. Kam attended medical school at Techneion Haifa in Israel. After residency,
during Israels 1982 War in Lebanon, Dr. Kam was in charge of the Emergency
Department in his hospital and cared for many soldiers with devastating war injuries,
including lethal liver injuries. A surgeon from the University of Pittsburgh visited his
facility. Dr. Kam expressed his interest in doing transplants. The surgeon went back to
Pittsburgh and spoke to Dr. Starzl. In 1984, Dr. Kam was granted a surgical fellowship
in Pittsburgh with Dr. Starzl, after which he became a faculty surgeon at Pittsburgh in
1985. He was doing a large number of transplants during this time. He then went back to
Israel, planning to develop a transplant program there. In 1987, Dr Alden Harken, then
Chair of the Department of Surgery at the University of Colorado, became interested in
reviving the Transplant program in Denver. Dr. Kam was available. In 1988, Dr. Kam
came to Denver and began to develop the Liver Transplant Team described below.
Dr. Kam is currently the Chief of the Division of Transplant Surgery and, along
with fellow-surgeons Michael Wachs, Thomas Bak, and Michael Zimmerman, does all of
the liver and kidney transplants done at the University of Colorado Hospital (UCH).
They also are on staff at The Childrens Hospital and cover for the Childrens transplant
surgeon, Dr. Fritz Karrer, if needed. In addition, the group is contracted with
4


Presbyterian St. Lukes Hospital (PSL) in Denver to provide kidney transplant surgery
services at that facility. The surgeons are on call (on a rotational basis) for both UCH and
PSL. Thus far, approximately 1250 liver transplants have been done at the combined
programs at University of Colorado Hospital and The Childrens Hospital.
The surgeons have surgical, clinical and research responsibilities. They cover in-
patient call, attend clinics, and oversee the postoperative recoveiy of kidney and liver
transplant patients. In addition they each participate in multiple weekly meetings and
conferences.
When an organ (liver or kidney) is available for transplantation, die surgeon
confers with the transplant coordinator on call to determine the best recipient for the
available organ. They also assign members of the surgical team to recover the available
organ(s).
In addition to their clinical and research projects, the transplant surgeons also
participate in and contribute to meetings around the country and around the world. One
of them is also a sitting member on the Regional Review Board for UNOS and, as such,
must attend periodic national UNOS meetings where policy changes are discussed and
future plans developed. UNOS will be explained in detail below.
It is because of the vision of Dr. Kam in 1988, in collaboration with Dr. Greg
Everson in Hepatology, that the Liver Transplant Team grew into its present form.
Through their energy and determination, meeting the many obstacles that occurred along
the way, obstacles that are inherent in an academic hospital environment, a team has been
5


created that works. It is functional; it is effective; and it is growing all criteria for a
successful enterprise.
James F. Trotter, M.D., Associate Professor of Medicine, Transplant Hepatology
Dr. Trotter earned his MD degree from Emoiy University in Atlanta, Georgia.
His residency was completed at the University of Texas, Southwest in Dallas, Texas,
followed by a fellowship at Duke University. After completing his fellowship, he
remained at Duke as a faculty member until 1999 when he joined the Liver Transplant
Team at the University of Colorado as an Assistant Professor of Medicine. In addition to
his clinical responsibilities, Dr. Trotter is the primary investigator on multiple current and
on-going research projects, in addition to studies that are being simultaneously conducted
at multiple transplant centers around the country.
Dr. Trotters colleagues in die Hepatology Practice include Gregory T. Everson,
M.D., Professor of Medicine, who was involved in liver transplant 1988 and has been
instrumental in developing the Transplant Team as it exists today. Lisa Forman, M.D.,
James Burton, M.D., and Hugo Rosen, M.D. (Professor and Division Chief of GI
Medicine) complete the Transplant Hepatology portion of the Team. Responsibilities for
the care of patients who are in the hospital on the Hepatology Service are shared on a
rotational basis among the hepatologists. They also attend Post Transplant Clinic on
Monday and Thursday mornings, again on a rotational basis. The hepatologists are
continually available to the hepatology nurses for the hepatology population (4500
6


patients and growing) and transplant coordinators for the post liver transplant population
(836 patients to date) on issues of evaluating medical data, assessing symptoms,
prescribing medications, and developing treatment plans. In addition, they each have
their own clinics for hepatology patients and are primarily responsible for the follow-up
required for this group (evaluating medical data, assessing symptoms, prescribing
medications, and developing treatment plans).
The hepatologists are responsible for procedures performed for hepatology
patients and post liver transplant patients such as liver biopsy, colonoscopy, upper
endoscopy, and large volume paracentesis of ascites. They each participate in multiple
weekly meetings and conferences. In addition to clinical activity, they are also members
and participants in various professional organizations and societies, attending national
and international transplant and liver disease meetings throughout the year.
Tracy Steinberg, BSN, MSN, CCTC, Lead Liver Transplant Coordinator
Ms. Steinberg earned her BSN and MS in Nursing at the University of Colorado
School of Nursing. She has achieved the professional designations of Clinical Nurse
Specialist in Liver Transplant and Certified Clinical Transplant Coordinator. Ms.
Steinberg has served for 22 years at the University of Colorado Hospital as a bedside
nurse, nurse educator, and then joining the Liver Transplant Team in 1993. She is the
lead transplant coordinator of a four member team.
7


Generally, Ms. Steinberg oversees the activity of the other transplant
coordinators and their support staff. She assures that all aspects of post transplant care
are carried out efficiently and effectively. In addition, she is responsible for managing
the Liver Transplant Waiting List (480 patients) and is responsible for listing patients
with UNOS and maintaining the UNOS database (UNET) with current demographic, lab
and medical data. Ms. Steinberg takes donor call for liver transplant, assisting the
surgeon and Donor Alliance with the appropriate placement of livers. Part of this
responsibility includes notifying a patient that a liver has been found for them. She
assures that there are no medical concerns (sickness or new diagnoses) that would
preclude the patients current eligibility for transplant and makes arrangements for their
admission to the hospital in preparation for liver transplant surgery.
Ms. Steinberg also plays an active role in patient and family education, both pre
and post transplant. She conducts a weekly class for patients who are being evaluated
and their families, in which all aspects of the transplant process are explained in detail.
She is responsible for discharge teaching for transplant recipients and families after
transplant. She attends clinic and cares for the post liver transplant population in the
long-term. In addition to her clinical responsibilities, Ms. Steinberg attends multiple
weekly meetings and records the discussion on each patient. The discussion
documentation is then appended to the Transplant Database where the data is
permanently available to the Team (including insurance company case managers) for
8


future treatment planning and decision-making. For the past fourteen years, Ms.
Steinberg has played a pivotal role with the Transplant Team.
Catherine Ray, BSN, MA.Lead Hepatology Nurse Case Manager
Catherine Ray earned both a BA and MA in Health Education from the
University of Northern Colorado in Greeley. She subsequently earned her BSN from the
University of Colorado School of Nursing. She started working with the University of
Colorado Transplant Team in 1993. She is currently the lead hepatology nurse case
manager. Ms. Ray describes her role as one in which she coordinates the care of pre-
transplant patients and follows them while on the Waiting List. She arranges for closing
any procedural deficits that may exist and prepares the listing dossier on each patient
scheduled to be presented to the Liver Selection Committee. Her attendance at this
meeting is required. She is responsible for assuring that listed patients get their routine
lab draws in a timely way so that their listing status is uncompromised.
Ms. Ray oversees the activity of the hepatology case managers, including two
and a half nurses, and is responsible for training these individuals. Ms. Ray also attends
multiple weekly meetings. In addition, Ms. Ray is responsible for directing the activity
of the Medical Assistants in the Hepatology Clinic. The Hepatology Clinic currently has
approximately 4000 active patients, with another 480 who have been listed for liver
transplant. The Hepatology Clinic takes in approximately 40 new patients every month.
9


This is a rapidly growing and demanding practice. Ms. Ray is instrumental in the smooth
functioning of this facet of the Liver Transplant Team.
Mary McClure, BSN, Liver Transplant Coordinator
Ms. McClure earned her BSN at University of Northern Colorado. She then
worked in the Operating Room at UCLA from 1981 to 1998 as scrub nurse and
circulating nurse. She was involved in liver transplant cases during that time. She then
came to University of Colorado Hospital as Charge Nurse in the Operating Room. In
1999, Ms. McClure joined the Liver Transplant Team as a Transplant Coordinator. She
is responsible for live liver donor evaluations. She provides full information to potential
donors about the surgery, post donation hospital course and the expected postoperative
recovery.
In addition, Ms. McClure, along with the other transplant coordinators,
coordinates the care of all post liver transplant patients. This involves discharge teaching
after the surgery, attending clinic on Monday and Thursday mornings, and monitoring the
patients medications, symptoms, and well-being as it relates to the liver transplant.
Transplant coordinators are often the patients primary source of information about their
disease and necessary treatments. At least 50-60% (sometimes more) of the day is spent
on the telephone. Prescriptions must be called in, prior authorizations obtained as
needed, and the effectiveness of the medications and possible adverse effects assessed.
10


Transplant coordinators function as liaison between the patient, the transplant
surgeons and hepatologists, and outside physicians (primary care providers or
gastroenterology specialists) who may not have any experience with liver transplant
patients. The Transplant Coordinators are responsible for overseeing their administrative
support staff in the scheduling of procedures (both routine and urgent), retrieval and entry
of lab results into the database, and day-to-day functions of the unit. An average of 40-50
sets of labs are reviewed daily, more than 75 sets on clinic days. Determinations are
made as to any symptoms the patient may be experiencing, abnormalities in the lab
results that require intervention, along with accurate communication of the patients
situation to the hepatologist who will determine if there is a need for action. In addition,
the transplant coordinators attend multiple weekly meetings.
Transplant coordinators take night and weekend call on a rotational basis so that
patients have emergency access to the Liver Transplant Team 24/7. The on-call
coordinator must be available by telephone and pager around the clock. Patients who
have an urgent problem contact the Answering Service and the coordinator is paged. The
coordinator assesses the situation, contacts the hepatologist on call as needed, and directs
the patient in the details of care required. The coordinator may direct the patient to either
go to the Emergency Department immediately or, in less urgent situations, appear at the
next Post Liver Transplant Clinic for evaluation. The role of transplant coordinator is a
demanding one, and it is key to providing unified and effective care to patients by a
multi-disciplinary team.
11


Lana Schoch, BSN, Liver Transplant Coordinator
Lana Schoch earned her BSN at the University of Saskatchewan in Canada. She
worked with Donor Alliance as an Organ Procurement Coordinator for 2 years and
subsequently worked at the University of Colorado Hospital in the Surgical ICU. Her
goal was to become a transplant coordinator, and, in 2004, Ms. Schoch joined the Liver
Transplant Team. She succinctly describes her role with the Transplant Team as taking
care of post liver transplant patients from surgery until they die. The scope of her role is
described in the section above with the exception that Ms. Schoch is not involved with
the Live Liver Donor population. Ms. Schoch provides comprehensive care to this
patient population and, as a liaison between the patient and physician, translates the
patients descriptions of symptoms and problems into a concise report for the physician.
Ms. Schoch serves as a patient advocate when necessary.
Michelle Miller, BSN
Michelle Miller earned her BSN from Augustana College in Sioux Falls, South
Dakota. She worked for ten years in a Pediatric ICU, specializing in Pediatric Trauma
and Respiratory Care. She then went on to work as an Organ Procurement Coordinator at
Donor Alliance for two years. Ms. Miller is the newest addition to the Liver Transplant
Team, starting her role as transplant coordinator in April of2006. Her role with the
Team is identical to Ms. Schochs although they care for a different group of patients. In
12


the past year, due to growth of the program, it was necessary to divide up patients
alphabetically among the transplant coordinators. Each one serves approximately one-
third of the total group. Ms. Miller notes that, although patient care is supposed to be
transplant related, patients tend to consult the Team about other issues and request advice
and direction, largely because we respond quickly and have such a close relationship
with the patients. Ms. Miller has made a very strong start with the Team.
Michael Talamantes, MSW, LCSW
Mr. Talamantes earned his MS in Social Work at University of Texas in
Arlington. He completed a graduate internship in the Pediatric Transplant Program at the
University of Texas SW Medical Center, Childrens Medical Center in Dallas, Texas. He
went on to be the Oncology/Bone Marrow Transplant Social Worker in Pediatrics. Upon
moving to Denver, Mr. Talamantes joined the Adult Liver Transplant Team at the
University of Colorado in 1992.
Mr. Talamantes is the lead social worker on the Liver Transplant Team. He
oversees an associate, Layce Cahill, MSW. Since 1995, Mr. Talamantes has been a field
instructor for the MSW program at the University of Denver. He has trained eleven
social workers, all of whom have gone on to full-time jobs in the medical field, many of
whom are involved in some aspect of transplant care. Mr. Talamantes and Ms. Cahills
role with the Transplant Team is a demanding one. They provide psychosocial
assessments of patients to determine candidacy as a transplant recipient or live liver
13


donor. They provide assistance with adjustment to illness issues and provide resource
referrals (regarding insurance issues, assistance programs, rehabilitation programs). They
are also involved in discharge planning, and are the primary patient advocates when
transfer to a rehabilitation facility, nursing home or hospice is required. The social
workers also attend multiple weekly meetings with the rest of the Team.
The social workers facilitate the Liver Support Group (described below)
composed of both pre and post transplant patients. Lastly, the social workers publish a
quarterly newsletter that is sent to all hepatology/liver transplant patients. It includes
news articles of interest that apply to changes in insurance plans, Medicare policy, and
other relevant topics, personal experience pieces, and updates on the activities of other
patients (babies born, trips taken, educations completed, etc.) that are submitted by
individual patients for sharing with the others.
Tim Brackett, BSN, JD.
Mr. Brackett earned his BSN from University of Colorado School of Nursing.
He worked as a floor nurse in the Transplant Unit at University of Colorado Hospital,
transferring to the Liver Transplant Team in 1999. He then pursued, and received, a law
degree from University of Denver Law School while working daily in the transplant
coordinator role. Mr. Bracketts computer skills are self-taught.
As dependence on the Transplant Database grew, he became part-time transplant
coordinator and part-time database administrator for the Liver Transplant Team. In
14


2004, he moved into full-time database administration for all of the transplant programs
plus hepatology at the University of Colorado. The team couldnt function as effectively
or efficiently as it does without Mr. Bracketts contributions.
The Transplant Database
The Transplant Database has its roots in a homely little Word document of
patient information that was used solely by the administrative support staff to keep track
of patients, insurance, referring physicians, etc. It was transferred to an Xcel file, then
moved into Access under Mr. Bracketts supervision. The database was expanded to
allow use by the transplant coordinators for printing and tracking Annual Review Surveys
(a survey sent to each post liver transplant patient annually to assess their ongoing
medical, emotional, and social status).
The database then grew into a comprehensive tracking system of post liver
transplant patients. It included a record of lab data, procedure data, insurance
information, and referring physician information. The Liver Transplant group then began
to utilize the database for communications with outside physicians. Each time a patients
labs are reviewed, a letter is generated by the database and sent to the referring and/or
primary care physician as well as the patient. In addition, a lab order is generated that is
faxed to the patients outside lab designating die patients next lab draw date and what
labs are to be drawn.
15


The most recent modification involved creation of a method for entering clinic
note data directly into the database in a template format. These notes can then be
transformed into formal clinic note format and copied into the permanent electronic
medical record. This is quite an improvement over the hand-written, and sometimes
incomprehensible, clinic notes of past years. In addition, the minutes from the Liver
Selection Committee meeting, Hepatobiliary Conference, and Pathology Rounds can all
be entered directly into the database, allowing for more complete and centralized
documentation of patient care than has ever been possible. Copies of insurance cards,
insurance authorizations and important reports from other facilities can also be scanned
into the database for future reference.
In recent years, the database has been modified for the use of Hepatology,
Kidney Transplant and Lung Transplant. Although the Liver Transplant group still
maximizes utilization of the database, the other groups are using it more and more. Heart
Transplant will be the last group brought live on the database. The goal is to have all of
the transplant programs fully utilizing the database, with the conversion to electronic
media and away from physical charts complete by the anticipated move to the Fitzsimons
campus in May/June of2007.
It would not be an understatement to observe that the Transplant Database has
truly been a revolutionary development in the provision of care by the Liver Transplant
Team. Mr. Brackett estimates that, if we were still handling all of this information
manually as we did even five years ago, it would take twice as many transplant
16


coordinators and administrative support personnel to do the work that we do routinely
now.
Since the health care environment is continually changing, the Transplant
Database must be a dynamic tool. In order to stay current, we must continually respond
to the changing conditions around us. All members of the team have contributed ideas
along the way. Every user with a bright idea discusses it with coworkers and, if all agree
as to the ideas usefulness, it is presented to Mr. Brackett who then brings the idea into
reality in Access. The group adopts the idea and incorporates it into daily practice.
Ideas that dont work out are modified or eliminated.
The database has truly been an interactive creation. However, Mr. Brackett has
been instrumental in the realization of the end product. The Transplant Database is a
remarkable tool, and an essential one for the Liver Transplant Team.
Weekly Multi-disciplinary Meetings
The Team participates in numerous meetings on a weekly basis. The table below
provides an overview of these meetings. The list is not exhaustive, however. There may
be meetings with patient families to discuss treatment options. The Liver Selection
Committee may be convened emergently if there is a patient in liver failure who will die
without a liver in the next few days. The following table represents only regularly
scheduled meetings and conferences in which multiple members of the team are required
to participate.
17


Table 2.1 Transplant team weekly meetings
Name of Meeting Purpose of Meeting Participants Frequency
Surgery In-Patient Rounds Review data and condition on Surgery Service. Develop treatment plan for each patient Surgeons, surgical fellows and residents, transplant coordinators, nutritionists, pharmacists, nursing staff Daily (including weekends)
Hepatology In- Patient Rounds Review data and conditions of in patients on Hepatology Service. Develop treatment plan for each patient Hepatologist on Service, Hepatology fellows and residents, pharmacists, nutritionists, nursing staff Daily (including weekends)
Lab Rounds Review lab results on all post liver transplant patients Liver Transplant Coordinators. Problematic results are discussed with the Hepatologist on call Daily (Monday through Friday)
Check-Out Rounds Review lab results and symptoms of patients seen in the Post Liver Transplant Clinic The Hepatologist in clinic that day, surgeon, transplant coordinators, patient affair coordinators Monday and Thursday following the Post Liver Transplant Clinic
Donor Rounds Review lab results, CT scans and general condition of live liver donors Dr. Trotter, the study coordinator, Mary McClure Second Tuesday of each month
Annual Review Annual Review Questionnaire sent to patients in anniversary month A Hepatologist, surgeon, social worker and liver transplant coordinators Weekly on Friday morning
18


Table 2.1 Cont.
Name of Meeting Purpose of Meeting Participants Frequency
Liver Selection Committee Review all medical imaging and social work, data on potential liver recipients to assess appropriateness of listing for transplant, determine deficiencies in work-up, and to determine eligibility of potential liver donors for donation Surgeons, Hepatologists, Hepatology nurses, transplant coordinators, anesthesia, radiology, blood bank, residents, fellows, study coordinators, the database administrator, the contracting person, and the financial counselor Weekly on Thursday morning
Pathology Rounds Review all pathology specimens submitted during the prior week, both biopsy and explant specimens including slides from outside facilities Hepatologists, Hepatology nurses, transplant coordinator, various Hepatology and Pathology residents and fellows Weekly on Thursday morning
Hepatobiliary Conference Review all radiological imaging (CT/MRI, ERCP and PTC) performed on Hepatology patients and donors, and post-liver transplant patients Surgeons, Hepatologists, Body Radiologists, Hepatology nurses, transplant coordinators, Surgical and Hepatology residents and fellows, and the database administrator Weekly on Friday at Noon
19


The Liver Support Group
The Support Group is facilitated by the Liver Transplant social workers and
provides a venue for educational and supportive programs for both hepatology patients
and post liver transplant patients. The group provides the patients an opportunity to
network with other transplant patients and to encourage the ones still waiting for a liver.
In addition, various members of the Team are invited to make presentations or lead
discussions about liver disease and the complexities of transplant care at the groups
bimonthly meetings. The Support Group also sponsors an annual dinner wherein patients
and family get together for a pot luck and sharing of experiences. This is also attended
by members of the Transplant Team. It is gratifying to see patients recover and get on
with their lives. This also encourages patients on the waiting list and gives them a degree
of hope.
Several patients volunteer with our program giving them an opportunity to give
back to the program through patient visitation. One of our volunteers attends the
Wednesday morning teaching sessions and assists patients who are being evaluated in
any way necessary.
Jane Biglin, MBA, Manager, Division of Transplant Surgery
Ms. Biglin earned her MBA from Pace University in New York City. She is the
Division Manager for Transplant Surgery, joining the Transplant Team in 1997. Her role
is non-clinical in nature. In addition to supervision of the division administrative support
20


personnel, she provides financial oversight for the division, keeping a close watch on
both revenues and expenses. Ms. Biglin has been involved in the development of a
surgical fellowship program at University of Colorado as well as handling administrative
details for visiting surgeons from other countries (Korea, Japan, Australia, Sweden, etc.).
The Liver Transplant Team hosts an international meeting annually, called Controversies
in Transplantation. The meeting continues to be well-attended and successful, in part due
to Ms Biglins administrative oversight. Ms. Biglin has been instrumental in planning
several celebrations involving the entire Liver Transplant Team, patients and families. In
1998, she planned the 10-year celebration; in 2003, she planned a celebration of live liver
donors including donors and recipients; and in 2005 she planned another gathering,
celebrating the 1000(i> liver transplant since the program began in 1988. All of these
gatherings were well received by team members and patients alike.
Ms. Biglin is also involved in planning for the division. Most recently, the
planning aspect has involved the move to the Fitzsimons Campus in May/June of2007.
Ms. Biglin has been attending planning meetings from the beginning, initially
contributing her vision for a Transplant Center that would incorporate all transplant
programs and clinical activity in one location with shared resources. She continues to be
an important member of the transition team.
Ms. Biglin is also involved with community awareness programs through the
Donor Awareness Council. She participates in efforts to raise money for an endowed
chair position. In addition, she works closely with the Marketing Department to develop
21


informational brochures on liver transplant and live donor liver transplant for
dissemination in the community. Ms. Bigiin is a strong leader and a skilled
administrator.
Eileen McQuillan, BA. (Author), Lead Patient Affairs Coordinator
I earned a BA from Metropolitan State College, Denver, Colorado, and am
currently seeking an MA in Sociology from the University of Colorado at Denver. I
joined the Department of Surgery in 1987, working first as a medical transcriptionist and
then as a patient affairs coordinator (PAC) for two surgical oncologists in GI, Tumor and
Endocrine Surgery. In 199S, I transferred to Transplant Surgery at which time I was the
sole PAC working with post liver transplant patients. We had about 17S patients then.
As the program grew, it was necessary to add staff to meet the growing demands of a
growing patient population. We now care for 836 patients (as of this writing) and I
oversee the activities of three and a half PACs (Ronda Adams, Consuelo Montez,
Jennifer Truel, and Cynthia McCollom).
Our role with the Liver Transplant Team is to facilitate patient care. Each PAC
is teamed with a transplant coordinator and, together, are jointly responsible for patients
that fall within a designated portion of the alphabet. PACs assure that scheduling is
correct, insurance correctly assigned, all referrals and prior authorizations in place, and
procedures are scheduled in a timely way and as directed by the transplant coordinator
and/or hepatologist/surgeon. In addition, we are responsible for lab data entry and
22


maintenance of demographic and scheduling data in the Database and hospital scheduling
systems. We track patients who are delinquent for lab draws on a weekly basis, with
reminder calls and letters, if needed. We assure that surveillance procedures are done on
time. We assist patients with insurance and billing issues. We coordinate intake
appointments for patients who were transplanted at another center but wish to transfer
their care to the University of Colorado Hospital. We are responsible for staying current
on changes in the insurance world, staying up to date on the transplant contracts,
maintaining awareness of process changes and nurturing connections within the
University of Colorado Hospital as well as outside physicians offices and labs.
Patty Polsky, MBA, Senior Managed Care Administrator in Strategic Development and
Managed Care
Patty Polsky earned her MBA from the University of Phoenix in 1989. She
began work at the then Colorado General Hospital in 1974 as a secretary in the Out-
Patient Psychiatry Clinic. She then moved to a medical transcription position in
Radiology which she describes as a boring but educational job. She then went to work
for Dr. John Lilly in Pediatric Surgery from 1976 to 1985. She had several roles
including Coordinator of Fetal Medicine in Surgery and Nurse Recruiter. In 1988, with
the reinstitution of die Transplant Program at University of Colorado Hospital, Ms.
Polsky became the first transplant financial counselor with the program. Since then, she
moved on to be the Manager of Admissions. In 1998, she assumed her current role with
the Transplant Team.
23


Ms. Polsky is responsible for all managed care contracting for any transplant
service provided at University of Colorado Hospital. This includes both hospital
contracting and physician contracting through University Physicians, Inc. This is the
only setting in the University system in which contracting for both entities, hospital and
physician, are undertaken by a single individual, evidence of remarkable confidence in
her abilities by both organizations. Ms. Polsky oversees a team of four financial
counselors for solid organ transplantation. She is also responsible for revenue analysis,
assuring that patient accounts are reviewed and that each insurance plan has paid in
accordance with the transplant contract. Ms. Polsky settles accounts with outside vendors
involved in the transplant process such as Donor Alliance, outside labs, and the listing
fees for UNOS ($600 per patient listed). She also promotes reimbursement through
review of the Medicare Cost Report
Ms. Polsky brings a broad business and medical background to her role with the
Transplant Team. It is as necessary to provide responsible financial attention to the
business of transplant as it is to the medical care side. The Team and the associated
facilities must observe sound business practice, wherever possible, in order to assure the
long-term survival of our program. Ms. Polsky ably serves this role.
24


CHAPTER 3
THE PROCESS OF LIVER TRANSPLANT
The Roots of Liver Transplant in Colorado
Sir Isaac Newton (1642-1727), a British, physicist, mathematician and
philosopher, said, If I have seen further [than certain other men] it is by standing upon
the shoulders of giants (http://www.bartlebv.eom/66/l 8/41418.html. 3-2-07). This
statement is true in physics, mathematics, and philosophy; it is true in sociology; and it is
certainly true in transplant medicine and surgery. In the beginning of transplant, there
were a handful of physicians and surgeons who envisioned a future in which defective
organs could be replaced and lives saved. Among these is Thomas Starzl, M.D., a giant
of the first order, who pioneered transplant surgery at die University of Colorado in the
1960s.
In his book, The Puzzle People (20031. Dr. Starzl describes the genesis of
transplant, from the first attempts in the lab in Colorado, through to successful
transplantation that has now become almost routine. Dr. Starzl also discusses the
significant political and institutional obstacles to bringing transplantation into the
mainstream. It was a difficult and lengthy battle but one worth fighting. He notes, A
great advance necessitates the overthrow of an established dogma (Starzl, 2003, pg 134).
In this case, the established dogma, that replacing defective organs wouldnt work -
couldnt work and probably shouldnt be done in any case, didnt go peacefully. Dr.
Starzl carefully cites the plethora of discoveries made by hundreds (perhaps thousands) of
25


physicians and surgeons over die years, and the manner in which these discoveries made
transplantation possible. Advances in immunology, oncology, medicine and surgety
along with greater understanding of the dynamics of tissue rejection are cited in detail.
Discoveries of imuran and cyclosporine, the initial immunosuppressive agents used to
protect the grafts of transplant patients from rejection are explained. Each discovery built
on the ones that went before. In many cases, these brave pioneers learned more from
their failures than from their successes.
In his later years, while Chief of Transplantation at the University of Pittsburgh,
Dr. Starzl mentored numerous surgical fellows, many of whom now head transplant
programs around the country, including Colorados own Dr. Igal Kam who reinstated the
liver/kidney transplant program at the University of Colorado in 1988. It seems a fitting
legacy: that Dr. Starzls student should breathe new life into a program that Dr. Starzl
first built so long ago. This brief sketch of Dr. Starzls role provided above is cursory, at
best. Please refer to The Puzzle People for the complete story. Since 1988, Dr. Kams
group at the University of Colorado has performed 11 IS adult liver transplants and 135
pediatric liver transplants. Of the adult transplant patients, 835 are alive and being cared
for by the Liver Transplant Team. Many of the pediatric transplant patients have grown
up, and, when they reach adulthood, transfer their care to die adult program at the
University of Colorado Hospital.
26


United Network for Organ Sharing (UNOS) and the Organ Procurement and
Transplantation Network (OPTN)
Prior to 1984 and the passage of the National Organ Transplant Act (NOTA),
organ transplants had been taking place for about 20 years. There was tremendous
disparity of practice among transplant programs. The government got involved in 1968
when cadaveric donors were first used. It was necessary to delineate the factors that
constitute brain death and to establish guidelines for the timing in withdrawing care.
The Uniform Anatomical Gift Act of 1968 defined these boundaries. In the 1980s, there
was some selling of organs. Since the transplant list was increasing at an alarming rate,
and there were not enough organs to go around, transplant centers around the country got
creative. For example, some states passed laws preventing any donated organs from
leaving the state. Ethical allocation concerns were widespread. It was not uncommon
for transplant centers to place a patient in Status 2A (putting them at the top of the list)
and keep them in the ICU (even if this level of care was not required) until an organ
became available. It might be depicted as a free-for-all.
NOTA was the federal governments attempt to rationalize the process of organ
sharing. It established a private, non-profit entity that would be under contract to the
Health Resources and Services Administration (HRSA), an agency of the U.S.
Department of Health and Human Services (HHS). The entity was called the United
Network for Organ Sharing (UNOS). Through its contractual agreements with HRSA,
UNOS administers die Organ Procurement and Transplantation Network (OPTN). The
27


OPTN is described as a unique public-private partnership that links all of the
professionals involved in the donation and transplantation system
(http://www.optn.org/optn/ 1/28/2007). The goal is to bring some order and equity to
the organ allocation process, to increase the efficiency and effectiveness of the process,
and to ultimately increase the supply of this very scarce resource, donated organs eligible
for transplantation.
Tommy Thompson, Secretary of HHS at the time, was also instrumental in
bringing reform to organ sharing. In response to evidence of wrong-doing, he called in
the FBI and together they went into a major transplant center in the Midwest to
investigate their practices of organ procurement. It was found that patients were moved
up on the list inappropriately and transplanted under false pretenses. The institution was
then billing Medicare for these transplants. Clearly, this constituted Medicare fraud and
punitive fines were levied against the hospital. The entire transplant community noticed.
While UNOS cant stop inappropriate transplants, it can certainly sanction those who
violate the rules. A UNOS sanction could interfere with an institutions Medicare
funding for all services, not just transplants. Having Medicare provider status revoked
would be devastating to any hospital system.
Members of the UNOS Board of Directors are nominated by each transplant
center in the nation. These individuals are professionals within the transplant community
and bring a great deal of experience, commitment and technical knowledge to the
28


endeavor. These individuals also serve as the OPTN Board of Directors through which
policies and procedures are established.
The United States has been divided up into 11 regions based largely on
geographical factors. Colorado is in Region 8, along with Wyoming, Nebraska, Kansas,
Iowa and Missouri. Each region is represented on the Board of Directors and on each
standing committee. Each region also has administrators and councilors who coordinate
regional activity. In addition, a Regional Review Board made up of members from the
region make final determinations on requests for exceptions, a topic that will be
addressed in another part of this paper. The OPTN serves as a repository of data that is
available to federal, state and local governments, insurance and contracting interests, and
individuals. The data can be used to develop standards for the transplant community, for
development of legislative and regulatory policy, and for quality control
(http://www.optn.org/data/about/uses.asp. 3/2/2007).
Prior to 2002, patients were listed into one of four categories that delineated the
medical urgency of the patients condition. A scoring system had been devised that
included some lab results but was also largely subjective since it was based on symptoms.
Because symptoms can be interpreted differently by different doctors, there was great
variability within and between centers on the designations of severity of condition. In
2002, OPTN/UNOS committees developed a model for objectively scoring a potential
transplant patients medical condition for listing purposes
29


(http://www.unos.org/SharedContentDocuments/MELD PELD.pdf. 3/4/2007). The
system is known as MELD/PELD and will be discussed next.
Model for End Stage Liver Disease (MELD); Pediatric Model for End Stage Liver
Disease (PELD)
As more and more liver transplants were being done around the country, it
became clear that, due to the inherent subjectivity of listing criteria, the basic system of
organ allocation required repair. Patients were being listed and transplanted, sometimes
ahead of patients who were sicker. Waiting time on the list was die primary criteria for
determining which patient received the next liver. Since patients can remain on the list
for years and be relatively well throughout, this was not an effective way to allocate
livers. In addition, it was possible to cheat with the old system. The liver transplant
community demanded a more objective method for determining status for transplantation.
A paradigm shift was needed. MELD/PELD was the result.
MELD is a tool for determining the medical urgency of an adult patients
condition, and subsequent priority on the Liver Transplant Waiting List. It is a numerical
scale ranging from 6 (too well to transplant) to 40 (seriously ill). The score is determined
by a calculation of blood chemistry parameters including bilirubin (ability of the liver to
excrete bile), INR (prothrombin time/intemational ratio, a measure of the livers ability to
manufacture blood clotting factors), and creatinine (a measure of kidney function since
compromised kidney function is often associated with liver disease). It is generally
30


agreed by UNOS and members of the transplant community that a patient with a MELD
greater than 40 is too sick to transplant and would probably not survive the surgery.
PELD refers to the Pediatric End Stage Liver Disease Model. While the
calculation for pediatric patients is somewhat different, the end result is the same an
objective measure of the severity of the patients disease and consequent urgency of liver
transplant.
Within the MELD/PELD system, there is an exception known as Status 1.
Patients who have been made Status 1 have acute liver failure (sometimes sudden in
onset as in fulminant hepatic failure), or due to complications of transplant surgery such
as primary nonfunction of the liver graft (cause unknown) or hepatic artery thrombosis
(clot formation that prevents blood flow to the liver). Life expectancy without transplant
is from hours to 7 days in duration. A very small percentage of patients (4% or less) are
transplanted as Status Is.
According to Ms. Steinberg, each patient on the Liver Transplant Waiting List
must get regular lab draws. The frequency of draws is determined by their MELD score
and consequent priority on the list. For example, patients with a MELD of less than 10
must get labs once a year while patients with a MELD greater than 25 must get labs
weekly. Failure to comply with their specified regimen will cause the patient to lose their
priority on the Waiting List. MELD labs that are current within 48 hours of draw must be
posted twice weekly on the on-line UNOS database (known as UNET). UNET
automatically drops a patients MELD score for lack of current lab data or, if the patients
31


condition worsens as evidenced by worsening lab results, increases the MELD, again
automatically.
Under the MELD/PELD system, the sickest patients get transplanted first and
time on the Waiting List is irrelevant. It should also be noted that, at the time of
transition to the MELD/PELD system, patients already listed, who had been on the list
for some time, lost their advantage to the need for objectively established criteria
unfortunate but necessary in the name of justice.
While MELD/PELD represents greater patient equity and is widely regarded as
an improvement over the old system, it is not necessarily an optimal indicator of a
patients severity of disease. For example, there is no way to factor into the MELD
calculation such symptoms as hepatic encephalopathy (severe cognitive impairment) or
ascites (intra-abdominal fluid collections) that are both symptoms of end-stage liver
disease. These conditions, while not inherently life-threatening, do compromise a
patients quality of life and are considered problematic.
In some cases, a transplant center might decide to petition the Regional Review
Board (RRB) for an exception because the team believes that the patients MELD
determined priority on the list does not accurately reflect his/her true medical condition.
The RRB must decide if the patient does, indeed, have an increased risk of mortality that
is not addressed by the MELD score.
There are two types of exceptions: a standard exception for hepatocellular
carcinoma or liver cancer > 5 cm or cholangiocarcinoma, Wilsons disease (a genetic
32


diseases in which copper in appropriately metabolized) or prior transplant with a DCD
(donation after cardiac death) donor. A special case exception for conditions such as
refractory encephalopathy, refractoiy ascites, and pulmonary hypertension, for example,
may be granted. Each of these exceptions gives the patient an additional 22 MELD
points, added to their natural MELD points based on lab criteria. The change is made
automatically in the UNET database once the RRB grants the exception. The upgrade
only lasts for 3 months. At the end of 3 months, if the patient hasnt been transplanted,
he/she must be reassessed (including CT scans or whatever other testing is required to
provide justification for a renewed upgrade) and the RRB petitioned again for an
exception.
Many physicians and surgeons in the greater transplant community believe that
abuses still occur, primarily in the exception request process. Some regions report a
large number of exceptions while others report relatively few. The cause of disparity is
subject to debate. At the same time, some physicians believe that encephalopathy and
ascites should not be acceptable criteria for granting an exception. There is also current
discussion in transplant venues wherein the participants even dispute the number of
MELD points that should be granted for each exception. There is a call for development
of national standards that govern MELD/PELD exception criteria.
Since the worldwide transplant community is a relatively small one, it is certain
that these issues will be discussed and debated until satisfactory resolution is reached.
33


There is a continual drive toward more equity, more justice, and better policies for
sharing of this incredibly valuable, but scarce, resource.
Evaluation and Listing for Transplant
A patient is referred to the University of Colorado Hospital Hepatology Clinic for
evaluation and treatment of liver disease. When the patient checks in, their photo is
taken, and pertinent data is entered into the Hepatology portion of the Transplant
Database. The patients records are reviewed, a history is taken from the patient, and the
patient examined. Additional labs may be required to further assess the nature and extent
of the patients liver disease. These are ordered and subsequently reviewed. If the
patient is determined to be an appropriate candidate for liver transplant, the financial
counselor is notified and begins the process of obtaining authorizations for the formal
transplant evaluation from the patients insurance company.
Once insurance authorization is obtained, additional tests and procedures are
ordered. These include CT or MRI scans to determine size of the liver and to look for
any undetected tumors or problems. The bile ducts must be assessed along with vascular
structures. Some patients have extra vessels or bile ducts that could complicate the
transplant surgery later on, so it is essential to clearly delineate all pertinent structures.
Lab results to exclude other disease processes must also be obtained. These include HTV
testing, hepatitis serologies, tumor markers, INR (a measure of the bloods ability to form
clots, compromised by liver disease), and any other labs that may be needed to clarify the
34


patients medical situation as determined by the hepatologist. Liver biopsy must be
performed on each patient to confirm the diagnosis with pathological scrutiny of the
specimen. Some of the patients may be eligible for studies and are referred to the study
coordinators for this purpose. Some of the labs/procedures are standard and some are
driven by the diagnosis. For example, a patient diagnosed with primary sclerosing
cholangitis (PSC) or Wilsons disease (a genetic problem) will not require random urine
alcohol screens.
The following are rough estimates of the frequency of disease processes
represented in the hepatology patient population. Approximately 40% of the hepatology
patients have hepatitis C. Of these patients, half are also alcohol abusers, and 1/4 have
liver cancer. Those with alcoholic cirrhosis comprise approximately 10% of the patient
population. The liver cancer group is growing, 25% of current patients. It should be
noted that a patients chances of being diagnosed with liver cancer increase the longer
they are on the list, largely due to improvements in cancer screening among the listed
population. Other diseases such as primary sclerosing cholangitis and primary biliary
cirrhosis (due to bile duct strictures) account for another 10%. Autoimmune hepatitis and
Hepatitis B patients compose another 10-15% of patients. Genetic problems causing
liver disease occur about 5% of the time. Other causes of liver failure including
cryptogenic cirrhosis and fulminant liver failure (neither of which have an established
cause) occur in less than 5% of the patients. The above very rough percentages do not
35


add up to 100% because there is some overlap among diagnoses with some patients
having more than one diagnosis.
The Hepatology Clinic takes in 40 new patients every month, or 480 new patients
per year with 4000 active patients seen at this time. Of these, 480 are currently on the
Waiting List for liver transplant. Four to five patients are presented to the Liver Selection
Committee every week, three of which are usually listed for transplant. The others
require some further evaluation or need adjustments to social situations or financial
situations, or they do not meet the Teams criteria and may not be considered good
candidates for transplant.
Patients who are going through transplant evaluation must also meet with a
hepatology case manager, a transplant surgeon, a transplant coordinator, a social worker,
possibly a psychiatrist and the financial counselor. These meetings are all organized
within a 2-day period, along with any lab draws and radiological imaging and cardiac
studies that may be required. During the week of evaluation, on Wednesday morning,
two classes are presented to the patients being evaluated and their family members. One
is given by the hepatology case managers and describes the process of evaluation and
management of the patients care during the pre-transplant period. The other is given by
Tracy Steinberg who describes the Liver Selection Committee function, UNOS and the
listing process, a description of MELD and its role in the Waiting List, the various kinds
of livers that can be used (split livers, DCD, ECD and live donors), and what happens
when a donor organ becomes available. Patients are instructed in the pager system. Ms.
36


Steinberg also describes the selection of a recipient, the recovery of organs, admission to
the hospital for the transplant, post transplant care, the clinic, and the various
immunosuppression medications used to prevent rejection after the transplant. A
handout of the talk is given to each patient. In addition, each patient and family group
are interviewed individually by Ms. Steinberg after the presentation to answer any
specific questions they might have and to verify their demographic information.
Each patient meets individually with a social worker. The family group and/or
care provider will meet with the social worker as well. The social workers are
responsible for doing a psychosocial assessment of the patient to determine candidacy.
They obtain a psychological history (verifying this with a significant other) and any
issues or concerns are referred for a psychiatric assessment. In addition, the social
workers assist with adjustment to illness issues, resource referrals, and discharge
planning. It is important that both the patient and care providers have a clear
understanding of the process and have realistic expectations about the surgery and
postoperative recovery. There is a psychosocial profile that indicates a greater chance of
success and/or compliance after transplantation occurs. First, the patient should have a
significant other (spouse, relative or close friend) who will be involved in their
postoperative care. Patients who are knowledgeable about their disease process, are
comfortable with the medical care system, and with no previous history of substance
abuse or psychiatric problems are more likely to do well. Patients who live a long
distance away have special transportation problems that may interfere with post
37


transplant care. These concerns also must be evaluated and addressed appropriately. A
formal report is made by the social worker, documenting their observations and concerns
relative to the patients suitability for listing. The social workers acknowledge that the
profile is not a guarantee of success after transplant and is meant for guideline purposes
only.
All of the testing and evaluation data for each patient to be presented is gathered
and prepared for presentation to the Liver Selection Committee. This process takes
approximately 2-3 hours. In the pre-Transplant Database world, it generally took 2 days.
The Liver Selection Committee meets on Thursday morning at 7:00 am. This
multi-disciplinary committee is comprised of those individuals that met with the patients
earlier in the week (surgeons, hepatologists, case managers, transplant coordinators,
social workers) along with radiologists, anesthesiologists, a representative from the Blood
Bank, and the transplant financial counselor who is working to obtain insurance approval
for transplant. The goal is to 1) fairly apply the rules of UNOS and the Transplant Team
and 2) decide the viability of each patient for liver transplantation or, if the patient is not
eligible for transplant, to determine alternative treatment options. In addition, a Professor
Emeritus of Gastroenterology, Marshall Freedman, attends the meetings. He acts as an
outside observer and vocalizes comments and questions that are often helpful in keeping
the group on track. Disagreements do happen but not frequently. Ultimately, the
transplant is a surgical procedure so surgical concerns have a great deal of weight. Social
workers have a voice as do the hepatologists. It is essential that all participants feel
38


empowered to share their information and views. According to Dr. Trotter, Dr. Kam is
uniquely good at this [empowering others]. Unfortunately, we cant transplant every
patient that needs one. So, there is some negotiation that occurs from time to time.
Documentation of the proceedings of the committee meetings is essential. For medical-
legal reasons, there must be documentation available for every step of die evaluation and
listing process. There must be a logical progression in decision-making. Both patients
and the Transplant Team are protected by this documentation.
The criteria, both inclusion and exclusion, for listing are determined by UNOS
and the Liver Transplant Team and are very specific. They are outlined in the University
of Colorado Hospital document entitled Indications and Exclusion Criteria few Liver
Transplantation. Inclusion criteria include all criteria that would be considered as an
indication of the need for a liver transplant such as disease processes that lead to liver
disease and end-stage liver disease, and other symptoms that are manifestations of liver
disease, and liver cancer. Exclusion criteria are those that would exclude a patient from
consideration for a liver transplant. These include AIDS, malignancy outside of the liver,
septicemia (blood infections), severe underlying cardiopulmonary or systemic disease,
active alcohol or drug use, inability to give informed consent, and extreme psychosocial
circumstances (such as homelessness) that would result in inability to comply with
treatment. In addition, UNOS dictates that patients with liver cancer can be listed if they
have 1 lesion that is up to 5 cm in size, or 3 lesions up to 3 cm with each lesion being no
more than 3 cm. Lesion size is determined by CT scan prior to any interventions such as
39


i
i
chemoembolization (the blood supply to the tumor is embolized or blocked chemically,
causing the tumor to shrink and die). The Liver Transplant Team uses live liver donors
for patients who need a liver transplant, are otherwise healthy, but whose condition does
not meet the criteria noted above.
Patients may not be listed for transplant (officially accepted for transplantation)
if they show signs of noncompliance with care, are actively abusing alcohol or drugs, or
have developed serious medical conditions that compromise their status and are
consequent contraindications to transplantation. The patient is notified that they have
been turned down by the lead hepatology nurse case manager or one of the hepatologists.
Patients who are marginal know that they are likely to be turned down so this news isnt
a surprise just a big disappointment. Some physical problems cant be fixed and some
can. The patients candidacy can be revisited if the problem is resolved. If the patient is
formally listed on the Liver Transplant Waiting List, a letter is sent to the patient and
his/her referring physician notifying them of the patients listing status. The patients
data is entered into the UNOS database. Some patients may have vessels to their liver
that are clotted. This situation is noted as part of their listing documentation so that,
when an organ is recovered for this patient, vessels can be recovered as well. Once
listed, if a patient with alcoholic cirrhosis tests positive for alcohol on a random screen,
he/she is made inactive on the list Mandatory drug rehabilitation (with documentation of
attendance and achievement) ensues. The patient undergoes random, surprise drug
screens. They must achieve documented abstinence for 6 months to 1 year. When these
!
!
I
40


goals are met, the patient is presented to the Liver Selection Committee again to
determine if reactivation is appropriate. Recalcitrant alcoholics are delisted and may
never be listed again.
Once the alcoholic patient is listed, however, provided there are no intervening
problems and their drug screens remain negative, the patient is treated as any other. Once
listed, the MELD score is the primary determinant of priority on the list. Of note, there is
a fee of $600 per patient payable by the listing transplant center to UNOS at the time of
listing. Ever mindful of keeping costs down, the Transplant Team makes every effort to
make good decisions about which patients to list. Dr. Trotter estimates that 1/10
patients that need a transplant actually get one. The consequences of the Liver Selection
Committee decisions are heavy, indeed.
Clearly, there is a lot at stake for these patients. Compliance with care gives a
patient his/her best chance for a good outcome. However, medical or social factors may
compromise a patients ability to comply. For instance, hepatic encephalopathy causes
such confusion that a patient may miss appointments without meaning to be
noncompliant. A patient may not have ready transportation back and forth to the
hospital. These things are taken into consideration and a patient will often get a reminder
call from the team to get MELD labs, for example, since compliance with this aspect is
critical to maintaining his/her position on the list and ultimately getting a transplant.
41


The Importance of Social Support
It seems obvious that social support would be an important aspect of both pre and
post transplant care. Mr. Talamantes gives it a score of 10 on a scale of 10. Whether a
patient has been transplanted or is waiting, there are significant problems that must be
handled. Prior to transplant, many patients have overwhelming medical problems and
severe illness that lead inevitably to social and financial problems. The patient may not
be able to work. The patient may not be able to retain insurance coverage. Disability
checks may not cover expenses. They may not be able to drive or handle any details of
living due to hepatic encephalopathy. In addition, they must come to grips with die fear
of dying, a fear that has become more immediate due to their illness.
After transplant, during the post transplant recovery, patients must make multiple
weekly trips to the hospital for blood draw or other treatments and doctor visits. Some
require in-home treatments, some of which is handled by their spouse or care provider.
Many post transplant patients find that their problems lean toward social ones,
maintaining insurance coverage being at the top of the list. This assumes that their health
status continues to be stable. If their condition deteriorates for some reason, even if the
change is temporary, the patient is back in the scary world where life is no longer certain
and health is not guaranteed.
In both scenarios, the patients spouse, significant other, relative or friend who
provides the majority of support, serves a critical role in the patients recovery. Most
patients agree that they could not cope if it werent for that care provider that took care of
42


details while the patient concentrated on getting better. The care providers are viewed,
by patients and team members alike, as heroes. It is not unusual for a patient to say
outright, I couldnt have done it without my wife (my friend, my brother)!
In this sense, the Transplant Team extends beyond the medical staff to include
those who care for the patients at home, day in and day out. To attempt to deal with end-
stage liver disease or to recover from a transplant without social support may very well
be impossible. Its not just a matter of transportation or cooking meals and doing
laundry. Someone needs to pay the bills. Someone needs to keep track of medications
and dosing at correct intervals. Someone needs to encourage the patient and stay
optimistic. Someone needs to help an encephalopathic patient be compliant with care.
Someone needs to be there for the patient, willing and able to provide or do what is
needed at the time.
Someone needs to be available for that special day when the transplant
coordinator calls to say ...
We have a donor!
Once the OPO representative (see below) has contacted the transplant surgeon
with the offer of a possible liver, the surgeon contacts the transplant coordinator on call.
Together they review the List to determine which patient would be an appropriate
match for the available organ. Criteria used in matching the organ with the recipient
include the quality of the organ (determined at recovery), the severity of the patients
43


disease (including MELD score), die size of the organ (liver volume determined on CT
scan), the size of the patient (both donor and recipient), the age of the patient (both donor
and recipient), blood type, and previous surgeries the recipient may have had that would
make the transplant surgery more difficult due to the formation of scar tissue intra-
abdominaliy. The surgeon determines which recipient is the best match, and also selects
a back-up in case the first choice cant be located.
The transplant coordinator contacts the patient, making them aware that a donor
has been found for them, and outlining details such as when they should arrive at the
hospital to prepare for the surgery and where to report. In addition,-the transplant
coordinator gives them other preoperative instructions including the appropriate period
for fasting prior to the surgery and when the case is expected to begin. Sometimes,
logistical difficulties are encountered. One patient was snowed in when he received the
call and was unable to get to Denver. Another was in an airplane on the way to Los
Angeles when he got the call. He made arrangements to catch a flight back to Denver
from LAX and was able to get the transplant after all. Occasionally, patient contact
telephone numbers havent been updated and the transplant coordinator wastes precious
time trying to locate a patient. It is each patients responsibility to assure that such
information is correct at all times. If the patient cant be reached or for some reason cant
get to the hospital, the transplant coordinator moves on to the backup patient. Because
time is a factor in this process (see below), it must be accomplished as efficiently as
44


possible. The coordination activity often happens in the middle of the night. Transplant
coordinators and transplant surgeons are a hardy bunch!
Meanwhile, the representatives of the OPO are hard at work, assuring that the
donor is cared for properly until organs can be recovered.
Organ Procurement Organization (OPO)
At a hospital somewhere in Region 8, a patient is identified as being near death
and as being a possible organ donor. Donor Alliance, the Organ Procurement
Organization (OPO) in Colorado and Wyoming is contacted. An organ recovery
coordinator (ORC) and social worker are dispatched to the hospital immediately. Thus
begins a behind-the-scenes flurry of very intense activity. The first step is to talk with the
families of the dying person. Social workers seek to educate, inform and counsel the
families during the process and, hopefully, obtain consents for organ donation. Once
consents are obtained, the ORC takes over. The goal is to 'fix die body in a state that
will preserve the organs long enough for the recovery teams to arrive. In other words, as
Ms. Miller puts it, the ORCs activity seeks to mimic life in a dead body. This is done
using hormone infusions, infusions of fluids, blood, electrolytes, and anything else that is
needed to keep the body viable until the recovery surgery can be performed.
The ORC becomes a step-in physician, writing orders and running codes
(hospital procedure for resuscitating patients after cardiac arrest). The ORC must
persuade physicians and other nurses to do what is necessary. Some community hospitals
45


have limited resources. In some donor cases, all of the hospitals supply of platelets,
fresh frozen plasma and blood may be used up on one donor. ICU staffing requires 1 on
1 care (1 patient, 1 nurse). Donors take a great deal of time and energy. Ms. Miller
indicates that taking care of a donor is just as hard as a trauma case. Ms. Millers most
difficult case went for 44 hours straight. She was able to grab a 3 hour nap in the middle.
This particular family was very happy that seven organs were placed. It was a way to
bring some good into a difficult, painful and tragic situation for the donor family.
Once the donors viability has been established and stability achieved, the ORC
runs the list with UNOS to find a list of patients with the correct blood type. They locate
the sickest patients in the region. The ORC then contacts the surgeon (whether at
University of Colorado Hospital or some other transplant center) to notify them of the
potential donor. The surgeon (after reviewing the list with the transplant coordinator)
decides on the recipient. This process is followed for every organ that will be recovered.
Operating Room time is scheduled. If it is more than a 2 hour drive for the procurement
team, a jet is reserved to transport the team back and forth. There may be different teams
from different transplant centers for different organs, and multiple jets may be required ~
a logistical challenge. In one scenario regarding a local (Denver) donor, 1 kidney stayed
locally, the other was shipped to California. The liver was shipped to Missouri. The
heart went to Utah. The lungs went to California. The pancreas went to Minnesota.
Typically, the team that recovers the liver can recover the kidneys as well.
46


Organs for transplantation must be recovered in the proper order. The heart and
lungs (inflated) must be removed first, then the liver (and vessels which can be frozen
and held for later use), and then the kidneys. If the jet for one of the teams is delayed, the
whole recoveiy must wait until they arrive. All surgeons must be present before the
recovery surgery can begin. Once the organs are recovered, the ORC must have ready a
complete copy of the donor chart for each organ recovered. Each organ is packaged and
sent off, along with the chart, to the receiving hospital where an anxious patient and
family wait for the life-saving surgery. No more than 12 hours can elapse between
recovering the liver and placing it in the recipient. The less time that goes by between
recovery of the organ from the donor and placement in the recipient, the more likely that
the organ will function well after transplant.
Ms. Schoch and Ms. Miller, having both spent time as ORCs, were in agreement
that it was a great job, for a while. ORCs typically last for 18-24 months. They simply
get burned out. Recovering organs from a donor is incredibly demanding, start to finish.
Usually it requires 18-36 hours of nonstop work. Then there is the paperwork. When
they arent coordinating a donor, they are back at the office, auditing the donor charts and
bills to assure that Donor Alliance is paid correctly for all services provided from consent
to transport to the recipients transplant center. In addition, they assure that the donor
family is not billed for anything. The job could be incredibly gratifying or incredibly
painful, depending on the circumstances.
47


Since both Ms. Schoch and Ms. Miller now work with the Liver Transplant
Team, they agree that seeing the recipients and watching them get well and get on with
their lives is of great benefit. It closes the loop for them. Having seen both ends of the
process gives them a depth of understanding that benefits patients and team members
alike. Because of their experience at Donor Alliance, they are both better able to care for
patients that have undergone this challenging surgery.
The Surgery
The transplant recipient arrives at the University of Colorado Hospital and is
admitted. (If the donor liver isnt found to be perfect, the patient will be sent home.) The
resident assigned does a preoperative history and physical and labs are drawn. The
patient has a preoperative chest x-ray and electrocardiogram. The results of these tests (if
within acceptable limits) provide clearance for the surgery. The patient is consented for
the surgery. The patient is then taken to the Preoperative Holding area where the history
and physical examination are reviewed. The patient meets the anesthesiologist and is
consented for anesthesia. Once the liver arrives in the Operating Room, and the
Operating Room technicians and nurses are ready, the patient is sedated and taken to the
room, positioned, and anesthesia induced.
Two surgeons are involved. One surgeon does the back table work, preparing
the donor liver for placement in the recipient. Preservation fluids are infused into the
liver at the recovery facility to keep it viable for transport and ultimate transplant. Before
48


it can be placed into the recipient, the liver must be flushed to remove all traces of the
these fluids. All vessels and bile ducts are trimmed and made ready for anastomosis to
the recipients own vessels and ducts.
Meanwhile, another surgeon is working on the recipient, opening the abdominal
cavity, dissecting down through layers of abdominal wall and through any adhesions
(scar tissue) that are present from prior surgeries, in preparation for removal of the
recipients diseased liver. Timing is critical.
Once all is ready, the liver is removed from the recipient and the donor organ
placed. Careful attention is paid to all anastomoses (the connection between donor and
recipient arteries, veins, and bile ducts). Suturing anastomoses is critical to assure that
strictures do not occur, obstructing either the flow of bile from the liver to the small
bowel or blood to and from the liver. Stents (open tubes) are stitched in place in the bile
duct anastomosis to prevent stricturing while the anastomosis heals postoperatively. The
bile duct stents are removed 6 months after transplant, if they are still present. Stents are
not placed in the arterial or venous anastomoses since removal at a later time would
require another major surgery. These anastomoses must be stitched in such a way that
there are no rough surfaces on which blood clots can form, possibly obstructing blood
flow to or from the liver graft. According to Dr. Trotter, suturing the hepatic artery is
an art form, and he attributes our surgical outcomes to the superior skills of the
transplant surgeons.
49


The moment when the vessel anastomoses are complete and the clamps are
removed is a magical moment. Oxygenated blood is pumped from the heart through the
aorta and the hepatic arteiy and into the liver graft. The liver instantly goes from a pale
beige color, to pink, to a deep, vibrant red. The liver graft immediately goes to work,
building clotting factors, recycling hemoglobin, and removing toxins from the body.
There should be a drum roll or trumpets to announce this event that seems to this
observer to be almost miraculous. Perhaps this is a demonstration, at least in lay terms,
of why a patient can be at deaths door one day, and on the road to recovery the next by
virtue of having had a liver transplant.
Getting back to die surgery, all anastomoses are checked and rechecked to assure
that there are no leaks or kinks. The needles and sponges are counted. The patients
incision is closed in layers. The patient is taken off the respirator and extubated in the
Operating Room. He/she is monitored closely in the Post-Anesthesia Care Unit (PACU)
and then, when stabilized, is taken to his/her room on the Transplant Unit or to the
Surgical Intensive Care Unit (SICU), as appropriate.
Several advances in surgical technique have not only improved outcomes at
University of Colorado Hospital but also have shortened patients postoperative stay in
the hospital. In the early days of transplant, a T-tube was used to drain the bile ducts
after a transplant. The tube was connected to a bag outside of the patient. Because all
oral medications ended up in the bag and not in the patient, patients had to have all
medications administered via the intravenous route. Elimination of the T-tube allowed
50


patients to start on oral medications sooner, and shortened their length of stay in the
hospital. In addition, abandoning the practice of venous-venous bypass during the
transplant surgery allowed for a shorter surgeiy an innovation that kept costs down.
The Operating Room is billed out by the minute. In 1988, a liver transplant surgery took
10-12 hours. Now, the surgeiy is routinely completed in 5-6 hours. Once the surgery is
complete, the patient is then taken off the respirator and extubated in die Operating
Room. Because of shorter surgery times and no need for venous-venous bypass, 70% of
patients dont even go to the Surgical Intensive Care Unit after a liver transplant. A
shorter surgery without ICU time may translate to a shorter recovery time for the patient.
Once the patient is settled in his/her room, postoperative management begins.
Recovery and Discharge
Upon arrival in his/her room, the patient is closely monitored with vital signs
(temperature, blood pressure, pulse and respirations) and lab tests. Pain medications are
given as needed. Patients are rounded on (seen, questioned, examined, and lab results
reviewed) daily by the Transplant Team (including surgeons, surgical residents,
transplant coordinators, social workers, floor nurses, and the transplant pharmacist). A
patients symptoms may indicate the need for further intervention of some sort. Follow-
up scans or ultrasounds may be indicated. If the patient develops signs and symptoms of
a non-transplant related nature, specialty consults are requested. For example, if the
patient demonstrates mental status changes, a neurology consult is requested. The nurses
51


on the Transplant Unit are all experienced in post transplant care. On more than one
occasion, it has been a floor nurse who identified a serious problem developing in a
patient after transplant and who then alerted the surgeons to the problem, possibly saving
the patients life.
There is a great deal of variation in this post transplant recovery process
depending on how sick the patient was prior to transplant. The degree of sickness before
transplant may be good indicator of how difficult and/or prolonged the postoperative
course will be. Generally, patients are in the hospital for 7-12 days after the surgeiy. By
discharge, the patient must be able to eat a regular diet, move bowels and urinate without
problems, be able to take all medications orally, and be able to ambulate without
assistance.
At this time, discharge teaching is performed by the transplant coordinator. The
patient, care giver and/or family members are instructed on the Post Liver Transplant
Clinic, times and location, and the procedure followed in clinic. In addition, signs and
symptoms of rejection and infection are described along with the particulars of wound
care, and what to do and who to call if they develop a problem both during and after
business hours. Medications are reviewed in detail. The patient is given a pencil sheet
that lists all medications, doses and frequency of dosing so the patient has a ready
reference at home. Prescriptions are called into the requisite pharmacy. Exercise and
activity restrictions are described. The patient and family are given a lesson on liver
transplant rejection. Rejection occurs when the bodys immune system recognizes the
52


liver graft as being foreign tissue and attacks it (as the body does when fighting off a
virus, for example). Rejection is indicated by a sudden elevation in liver function lab
tests, and the patient may experience other flu-like symptoms and/or pain over the liver.
Rejection is treatable and reversible, provided we (the patient and the team) stay on top of
things with regular lab draws and strict compliance with post transplant medications. The
patient is encouraged to call if they arent feeling well or develop a fever. The transplant
coordinator will also answer any questions the patient might have about their surgery or
aftercare.
Once their labs are stabilized, pain can be managed with oral medications, and a
protective immunosuppression blood level has been attained, the patient is ready to leave
the hospital to begin the out-patient postoperative phase of care.
Clinical Follow-up
Upon discharge from the hospital, post liver transplant patients may be seen as
often as daily or every other day if their condition warrants it. The patient will be seen
either in the Post Liver Transplant Clinic or in the Ambulatory Support Unit on non-
clinic days. Over the next few months, as the patients condition improves, the frequency
of visits lengthens from daily, to twice a week, to once a week, to every two weeks, to
once a month. It could be said that, when the patient is down to monthly visits, it is a
graduation of sorts. Routine maintenance care will be required for the rest of the
patients life, however.
53


Regular labs are a critical part of the follow-up. These labs (complete blood
count, comprehensive metabolic panel, and immunosuppression level) provide a snapshot
of how well the liver is working, whether infection is present, and how much
immunosuppression is being absorbed into the blood stream and, therefore, the level of
protection against rejection that exists. This lab data along with vital signs and symptoms
reported by the patient or care giver allow the Transplant Team to assess the patient and
to intervene as needed. Progress is monitored as frequently as is indicated by the
patients lab results or symptoms.
Formal Post Liver Transplant Clinic takes place every Monday and Thursday
morning. Patients are seen in the order in which they arrive. After labs are drawn and
vital signs taken, the patient is placed in an exam room. The patient is assessed by a
transplant coordinator who discusses their condition, any problems they may be having or
new symptoms that have appeared. An important portion of this discussion involves the
medication review. The patient was discharged with a pencil sheet that lists every
medication the patient is on, what dose they are taking, and how frequently it should be
taken. At each visit, the transplant coordinator assures that the patient is really taking
what we think they are taking, how much of it, and how often. This aspect is critically
important. The patient should have enough immunosuppression on board to protect
against rejection of the liver, but not so much that they experience unpleasant short or
long-term side effects. Many of the immunosuppression agents are nephrotoxic (hard on
54


the kidneys) and the team must be ever mindful of balancing these equally important
concerns.
The outcome of the patient/coordinator discussion is documented in the
Transplant Database. Lab results are automatically downloaded into the database from
the hospital lab computer system as they are completed. The database refreshes data
eveiy five minutes so current lab results may be available for review during the visit. If
the transplant coordinator feels the patient should see a doctor, the hepatologist or
surgeon then sees the patient, depending on whether the patients concerns are of a
medical or surgical nature. Wound checks are performed at each visit to assure that the
patient is healing properly. Sutures are typically removed three weeks after the
transplant.
The number of clinic visits on Monday and Thursday morning ranges between
10-20 patients. Some of these patients are just getting labs drawn and do not need to see
a transplant coordinator or doctor. Some patients just need to see a transplant
coordinator. Some patients are recently discharged from transplant and may be seen by
both the transplant coordinator and hepatologist and/or surgeon. Some patients come in
specifically for a doctor visit. If the patient is an old-timer (a long way out from
transplant) and wishes to have a check-up or has a veiy specific concern, the patient can
also be seen in a Thursday afternoon clinic wherein the hepatologists evaluate the
concern and modify medication regimens or suggest alternative medications to deal with
55


the patients problem. In whatever venue the patient is seen, a clinic note is prepared
within the Transplant Database and copied into the permanent electronic medical record.
At 12:30 pm on Monday and Thursday, the transplant coordinators begin to
review lab results of the labs that were faxed in from outside labs and have been entered
into the Transplant Database by the PACs. Any abnormal lab data is set aside to present
to the doctors at Check-Out Rounds that follow the preliminary review. At 1:30 pm, the
hepatologist that covered the Post Transplant Clinic, a surgeon, the transplant
coordinators, and the PACs meet to review each patients lab results and symptoms.
Decisions are made about further interventions that may be needed, now or in the future,
medication adjustments that need to be made, and when the next set of labs should be
drawn. All of this information is entered into the database. At the end of Check-Out
Rounds, the transplant coordinators call each patient that has a problem or question to be
answered or has a change of medication or dose change. The outcome of Check-Out
Rounds is e-mailed, faxed, or mailed to each patient reviewed that day along with his/her
referring doctors) or case manager. In addition, for those getting labs outside of the
University of Colorado Hospital system, a lab order is faxed to the draw station to be
available for the patients next lab draw.
The PACs schedule whatever procedures are required, obtaining the necessary
authorizations and doing any other related tasks. In some cases, by the time the
transplant coordinator calls the patient to tell them they need a liver biopsy, it is already
scheduled. Once scheduling of the procedure is confirmed, the information is entered in
56


the database and e-mailed (along with the pertinent lab data) to both the hepatologist who
will be doing the procedure and the transplant coordinator.
Patients needing only a lab draw can also come in on Tuesday, Wednesday or
Friday when Lab Only appointments are made and the blood draw station is not as
congested as it is on Monday and Thursday. The transplant coordinators also review
these labs, taking any problems to the hepatologist who is on-service that day. Again,
letters, e-mails and lab orders are sent out and patient calls made every day of the work
week.
In addition, patients call throughout the day to speak with a transplant
coordinator about new symptoms or problems, and medication requests, or a patient
affairs coordinator about insurance changes, scheduling problems, billing problems, or
other concerns. These calls are typically returned by the end of the day, every day.
Every effort is made to solve the patients problem or to redirect the call to someone who
can help. Because a transplant coordinator is on-call nights and weekends, every post
liver transplant patient can be in touch with the Liver Transplant Team 24/7.
Ms. Miller is the most recent hire on die Transplant Team. She states that,
compared to other institutions, This [Post Liver Transplant] is a finely tuned process.
57


Post Liver Transplant Treatment Issues
Post liver transplant patients can plan on having certain procedures after their
transplant. Some will be done on an urgent basis. Some will be elective. This list is not
exhaustive by any means.
1) Percutaneous liver biopsy A large bore needle is inserted into the liver
to obtain a tissue sample for pathological examination. Performed
annually for staging in hepatitis C patients and as needed for any patient
with abnormal lab results.
2) Transjugular liver biopsy Performed in Interventional Radiology under
radiological guidance for patients who are on blood thinners or whose
platelets are too low (poor clotting) to safely biopsy them via the
percutaneous route but whose condition requires a sample of the liver
graft for pathological examination.
3) Endoscopic retrograde cholangiopancreatogram (ERCP) Performed in
the Endoscopy Suite under radiologic guidance for patients with a duct-
to-duct bile duct anastomosis. An endoscope is passed through the
esophagus and stomach, into the small bowel and up to the bile duct
anastomosis. If the surgical stent is found, the stent can be snared and
removed. If bile duct stones are found, they are captured and removed.
If a stricture is found, it is balloon dilated and a stent placed to maintain
patency. If an ERCP stent is placed, repeat study is required to re-
58


evaluate the stricture and replace the stent if needed, every 6-12 weeks
(to prevent infection), until the stricture has resolved and stenting is no
longer required.
4) Percutaneous transhepatic cholangiogram (PTC) Performed in
Interventional Radiology under radiologic guidance in patients with a
Roux-en-Y anastomosis (a variation of the bile duct anastomosis). A
probe is inserted through the liver and into the bile ducts. Radiopaque
contrast is introduced into the bile duct to evaluate its patency. If there
is a stricture, a drainage tube is introduced into the bile duct and brought
out to a drainage bag on the outside of the patients belly. The bile duct
must be restudied and the tube changed every 6-12 weeks (to prevent
infection) until the stricture resolves.
5) Liver graft ultrasound with Doppler studies The liver, bile ducts,
arteries and veins are examined with ultrasound waves. The Doppler
studies allow assessments of blood vessel patency and blood flow
velocity to determine if there is an obstruction present.
6) Upper endoscopy (EGD) An endoscope is passed through the
esophagus, into the stomach and small bowel, and then slowly
withdrawn, examining all structures on the way out. Used to remove a
retained surgical stent from a bile duct anastomosis (6 months after the
59


transplant) or to assess symptoms such as nausea, vomiting or epigastric
pain.
7) Colonoscopy An endoscope is passed through the anus and rectum,
through the entire colon, and then slowly withdrawn. The procedure is
standard for cancer screening, important for immunosuppressed patients.
In addition, patients diagnosed with PSC may also have ulcerative colitis
and, therefore, require colonoscopies more frequently. The procedure is
also performed if a patient develops diarrhea that is resistant to treatment
or bloody stools.
8) Co-axial tomography and/or magnetic resonance imaging (CT or MRI) -
Scans of the abdomen are performed to evaluate new abdominal pain. In
addition, patients with the diagnosis of hepatocellular carcinoma (HCC)
are at higher risk of recurrence because of their immunosuppressed
status. Therefore, surveillance after transplant is done at 3 months, 6
months, 1 year, and every year thereafter. If the patient remains free of
tumor or metastases, the scans may be discontinued at 5 years.
9) A variety of other procedures may be required depending on individual
patient needs. Treatment plans are determined based on lab data, patient
symptoms, and/or physical examination.
There is always a degree of urgency in the care of post liver transplant patients.
They can suddenly develop a rejection episode, or clot off a vessel, or develop a bile duct
60


stricture. Procedures cannot be put off until the next available slot. As a result, the PACs
must be both resourceful and assertive in making arrangements for these patients. Most
procedures can be scheduled within a few days, a week at the most, unless the procedure
is truly elective in which case it is scheduled into the next available slot. Patients who are
accustomed to having to wait 4-6 weeks (or more) for procedures are usually surprised by
this level of service.
Outcomes
According to Dr. Trotter, statistical survival alter transplant is among the highest
in the country for the Liver Transplant Team at University of Colorado. Dr. Trotter
provides the data below:
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Table 3.1
Survival after liver transplant in years University of Colorado Liver Transplant Team National average
1 year 94% 88%
3 years 80% 75%
5 years 75% 60%
10 years 50% 50%
> 10 years 80 patients surviving Unknown
62


It should be noted that, if the patients on the Waiting List are included in the survival
statistics, our survival rates decrease. The Liver Transplant Team has a higher mortality
rate of patients on the Waiting List because the surgeons are very selective about what
livers to use. This is of great benefit to those who are transplanted. The wisdom of this
conservative approach is borne out by our survival rates after transplant.
Other centers may have a more aggressive policy toward liver transplant. This is
not necessarily a benefit to patients in die end. Henry Krakauer, Office of Health Policy,
Office of the Assistant Secretary for Planning and Evaluation, Department of Health and
Human Services states, ... a more aggressive transplant policy does not necessarily
achieve better ultimate results (http://aspe.hhs.gov/health/reports/organeval/orgtrans.htm.
3/2/07). Transplanting a patient earlier means that they will be on immunosuppression
for a longer period of time and, therefore, at a higher risk of cancers and/or compromised
kidney function. Transplanting lower quality organs may save a patients life in the short
run, but could lead to a higher rate of retransplant as these marginal organs fail.
A more conservative approach has been adopted at the University of Colorado,
not only in selecting livers for transplantation, but in post transplant follow-up in die
frequency of routine lab draws (every month). It is believed that this scenario provides
each patient with the best possible chance for a satisfying outcome. In the end, thats
what its all about.
63


CHAPTER 4
PROBLEMS TO BE SOLVED
Increasing the Donor Pool
Nationally, 17,200 patients are currently listed for a liver transplant. At
University of Colorado Hospital, 480 patients are currently listed for a liver transplant.
Every year, approximately 10% of the patients listed will die before getting a transplant.
Every year, that number is further reduced by the 85-95 patients that receive a liver
transplant. At the same time, that number is increased by the number of patients being
listed, approximately 150. The conclusion is obvious: we lose a little ground every year
- despite a reported increase of willing donors (30% per year according to Donor
Alliance), there arent enough donors to meet the rapidly growing need. The shortfall is
widespread, present in every country in which liver transplantation is performed.. In fact,
Eurotransplant (Europes counterpart to UNOS) reports a 40% mortalility rate on their
Waiting List. The problem is not going to go away.
As a result, there is much discussion in the transplant community about various
strategies for expanding the donor pool. One of the more intriguing ideas, shared by both
Drs. Kam and Trotter, and many others, is to create some means of compensation to the
families of cadaveric donors for this humanitarian service. In the USA, under the
Uniform Anatomical Gift Act and the National Organ Transplant Act of 1984, die
64


buying and selling of organs has been specifically prohibited (OPTN website at
http://www.optn.org/resources/bioethics.asp?index=3. 1/28/2007).
With a growing Waiting List and a relatively stagnant donor pool, something
must be done. There are ways to provide compensation to families of donors that
would avoid direct real-time payment between the recipient and the donor. Drs. Trotter
and Kam suggest the following: tax credits, paid funeral expenses, contributions to a
retirement plan, lifelong health insurance for family members, or contributions to a
college fund for the donors children. Any of these ideas could entice more families to
donate organs, particularly since there would be some concrete long-term benefit for the
family over and above any altruistic benefit they may derive. Dr. Kam also observes that
such an arrangement would prevent the black market in organs that occurs now.
Clearly, because the law currently expressly forbids such an arrangement, these
ideas will have to be addressed at the legislative level. It is to be hoped that some
modification of the law can be made in the future.
In the meanwhile, other strategies must be pursued. These will be discussed
individually. It should be noted that once patients are listed for transplant, they are sent a
document that explains each type of donor situation in detail. The patient must initial
each type of donor organ they are willing to accept, then sign and date the document.
The document must returned to Ms. Steinberg. This information is then included in the
listing information that is available to the transplant coordinator and surgeon when an
organ becomes available, and is incorporated into the permanent medical record.
{
i
65


1) Split liver transplant (SLT) In a case where the donor liver is pristine,
70% of it can be given to an adult recipient, and the other 30% to a child
recipient. The split must be performed in the field, so the recovery team
must be top-notch. In addition, both transplants must be performed at the
same center. The additional time required for shipping part of the liver
out to another center could compromise the organ, increasing the
possibility of graft loss. Bile duct complications may be slightly more
likely with this kind of transplant.
2) Deceased donor The donor is declared brain dead (a legal and medical
designation). The heart is still beating and bodily functions continue
with mechanical assistance in the ICU. The donors health history isnt
compromised by active or chronic disease or infection. Family members
consent to organ donation.
3) Donation after cardiac death (DCD) The donor is not technically brain
dead but has irreversible brain damage. The family wishes to donate
organs. The donor must be taken to the Operating Room, removed from
life support, and the organs recovered after the heart has stopped beating.
Dr. Kam feels this arrangement works well for kidney transplant but not
for liver transplant. The liver is damaged when the heart stops and there
is a consequent higher rate of graft loss.
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4) Extended criteria donor (ECD) The donor may only have one of the
following risk factors: older than 55 years, liver has more than 20% fat
on biopsy, or the donor requires IV blood pressure support. Dr. Kam is
clear in his view that, because older patients tend to die from sickness
rather than trauma, use of these organs can be risky. However, if there is
a patient on the Waiting List whose death is imminent, the older donor
may be the better alternative. Both E)rs. Kam and Trotter agree that
transplanting a hepatitis C positive liver into a hepatitis C positive patient
is a good strategy and may buy the patient some time, particularly if the
patient is very sick. The Liver Transplant Team has done liver
transplants using ECD donors on five different patients. Of these, three
are functioning perfectly, one has been retransplanted, and one is listed
for retransplant.
5) Opt-out method Some European countries have adopted an opt-out
plan wherein eveiyone is considered to be a willing organ donor unless
they formally opt-out of donation. Detractors say that it is still necessary
to obtain consent from families and consent is often withheld. A recent
article in a supplement of the Denver Post/Rocky Mountain News refers
to this method of increasing the donor pool (Ayres & Nalebuff, 2007).
While it works well in Spain, some question whether it would work in
the United States due, at least in part, to the difference in social structure.
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Still, it is worth looking into and, if it is turning up in the press rather
then academic journals, it may signal a change in societal attitudes that
could lead to increased rates of organ donation.
6) Various organizations, internet based, have sprung up in recent years.
These include Matchingdonors.com, Lifesharers.com, among others.
They claim to be able to get preferential consideration for members who
sign up as donors now but may later require a transplant. In addition,
there occasionally is a person who wants to donate part of their liver for
purely altruistic reasons with absolutely no bond with die potential
recipient. This person is known as the altruistic stranger. None of these
arrangements is acceptable to the Liver Transplant Team.
Lastly, the living liver donor (LLD) will be discussed, a topic that is important
enough, and complicated enough, that it will be discussed as a separate section.
Living Donor Liver Transplant
When a patient in need of a liver transplant has a relative or friend who is willing
to donate a portion of their liver, the possibility of a living donor liver transplant is
explored. In this surgery, the surgeon removes approximately 60% of the donors liver,
preserving blood vessels and bile ducts, and this donated partial organ is transplanted into
the recipient. Both donor and recipient livers are expected to regenerate (grow back) in
6-8 weeks. The liver is the only organ in the body that regenerates in this fashion and
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this quality of the liver is what makes living donation possible. The first successful living
donor liver transplant in the Western Hemisphere was performed at University of
Colorado Hospital in 1997. The donation was between sisters. The donor is alive and
fully recovered; the recipient is also alive but, unfortunately, had recurrence of her
disease process and is listed for retransplant at this time.
One great advantage to live liver donation is that, because a liver is not taken
from the shared organ pool that is managed by UNOS, a recipient who doesnt meet
UNOS criteria can still be transplanted. For example, a patient with a large liver tumor
that is greater than 5 cm in size or a patient with insufficient MELD points but severe
symptoms can receive a liver transplant from a relative or friend on their own time table.
In such cases, the recipient may be fundamentally healthier and may recover more
quickly because they didnt have to abide by UNOS rules.
Dr. Trotter is currently an investigator on a multi-center study (A2ALL) of living
liver donors. Each patient is assessed on a variety of medical and social criteria prior to
and after donation. The study coordinator is a key participant in the donors care by
obtaining lab data and follow-up studies at the proper intervals. The purpose of the study
is to identify and quantify the long-term consequences of live liver donation.
The process of determining a potential live donors suitability for donation is a
complex one. The evaluation process begins with a history and physical performed by a
hepatologist. The individual is informed of the risks of donation (a 1/300 chance of
death) at this time. Then, the patient spends some time with the study coordinator who
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introduces the patient to the pre-donation video tutorial. This is an interactive video that
ail donors must complete before moving on in the process. During the video, the patient is
asked specific questions such as Do you understand that you could die during or after
donation of part of your liver? The patient must answer Yes in order to go to the next
question. A No answer stops the process.
If the potential donor completes the video, he/she meets with a transplant
surgeon who describes the details of the surgery. The surgeon again explains the potential
risks of donation, both short and long-term. If the potential donor is still willing to
proceed, a battery of laboratory tests (the donor and recipient must have matching blood
types) are ordered that will reveal any underlying physiological problems. A liver biopsy
may be indicated. If so, this is performed. The potential donor will then undergo a CT
cholangiogram, a study conducted under CT guidance to assess the bile duct anatomy
(how many bile ducts and where they are located). Then, a CT of the abdomen is
performed to assess the vascular anatomy (how many arteries and veins feed and drain
the liver) and determine the potential donors liver volume. A liver that is too small would
eliminate the individual from donor evaluation.
If all testing is negative to this point, and the potential donor wishes to proceed,
the individual meets with a social worker. The social worker assesses the individual in a
number of ways. First, the social worker explores the emotional bond with the recipient.
It is important that there be a close emotional attachment between the donor and recipient
that would justify the donors risk. In addition, the social worker determines if there has
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been any coercion or pressure from any source (either people or programs). If there has
been coercion, and the potential donor really doesnt want to proceed, a means of escape
will be provided. Then, the individuals psychiatric history is obtained. The social
worker also interviews the potential donors significant other alone to verify the
psychiatric history. The person should have no active psych issues or active substance
abuse. A history of substance abuse would be further explored. Any issues or concerns
may indicate a need for consultation with a psychiatrist; the referral is made at this time.
Once these issues are resolved and documentation of previous mental health records, if
any, are obtained, the social worker discusses the individuals social support system
before, during and after the surgery.
Last, the social worker determines, through the use of open-ended questions,
whether or not the potential donor has realistic expectations about the surgery and
recovery. For example, if the individual only has a 3-week vacation available for the
surgery and recovery, their expectations about recovery are not realistic. The social
worker reiterates the short and long-term risks of liver donation.
If the individual still wants to proceed, he/she meets with Maty McClure, the
transplant coordinator that oversees the living donors. She reviews with them all of the
above information, answering any questions, assessing the individuals expectations, and
reinforcing the inherent risks, both short and long-term, of such a big surgery.
In Ms. McClures opinion, most of the potential donors have decided they will
risk h before they present for evaluation. In addition, she feels that, despite repeated
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warnings of the risks of surgery, living donors tend to underrate their personal risk in
favor of the more emotional need to help their loved-one. They are often shocked by
how bad they feel after the surgery and by how long it takes to bounce back.
Once all of these steps are completed and the potential donor is still willing to
proceed, the individual is presented to the Liver Selection Committee by Mr. Talamantes.
All psychosocial information is reviewed along with the findings of all testing. The
committee determines whether or not the potential donor is suitable. If so, all parties are
notified and the living donor transplant surgery is scheduled.
Dr. Kams PAC, Sandy Schultz, schedules the Operating Room. Two rooms are
required simultaneously, although the donor surgery does start first. In addition, Ms.
Schultz schedules preoperative appointments (history and physical exam, labs, EKG and
chest x-ray) for both donor and recipient. On the appointed day, both donor and recipient
are admitted. Once taken to the Operating Room, the donor surgery begins first. The
donor surgery is challenging in that sufficient bile ducts and blood vessels must be
remain for preservation of the donors organ, while the dissection must allow for
transplant into the recipient. Dr. Kam notes that liver resections have been done for SO or
more years; there is long history of experience behind the donor surgery.
Dr. Trotter notes a 38% complication rate in the A2ALL study (all participating
centers) but is careful to point out that the complications include relatively minor ones
such as abnormal lab results or anemia.
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Of the 119 live donor liver transplants performed at University of Colorado, two
significant postoperative complications have occurred. Both related to positioning
problems. One involved compression of the vena cava (the large vein that carries blood
from the lower body back to the heart) and a return trip to the Operating Room was
required to correct the situation. The other case involved temporary neurological damage
to the arm, again caused by positioning during the donation surgery. Both patients are
fully recovered. In addition, there has been a case of postoperative pancreatitis, an
incisional hernia, and occasionally patients develop anemia or diarrhea, all of which have
been successfully treated. There have been two donor deaths at other centers none at
the University of Colorado.
For all of die reasons outlined above, the Liver Transplant Team is not willing to
perform live liver donation on the altruistic stranger. The risks are too great and, in the
absence of a strong emotional bond between the potential donor and recipient, there is
little justification for any individual to incur the risks. Among the live donors at the
University of Colorado, one regrets taking the risk; this donor did not have a strong
emotional bond with the recipient.
Live liver donation continues to be discussed in professional venues, and
particularly Biomedical Ethical journals. The biggest ethical concern is that a healthy
patient (the donor) is taken to the Operating Room for a potentially life-threatening
surgery that does not benefit the donor directly. The donors benefit is the emotional
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need to help a loved-one. There is some debate as to whether this motive is sufficient to
warrant the risk.
Dr. Ayman Yosry (Professor, Hepatogastroenterology, Cairo University, Egypt)
presented some fascinating data about liver transplantation in the Middle East at the
Controversies in Transplantation meeting in March, 2007. He notes that both religious
and cultural barriers may preclude the use of cadaveric donors in the Middle East. For
example, the concept of brain death is not understood or accepted. In these countries,
death occurs only when the heart stops beating. In Egypt, transplantation using deceased
donors is illegal. Since the inception of the Egyptian transplant program, 349 live liver
transplants have been performed. Whereas 92% of the recipients were male, 76% of the
donors were female. In addition, transplantation is not a benefit of Egyptian health
insurance plans. Consequently, the only ones to receive a transplant of any sort in Egypt
are the ones who can afford to pay for it (approximately $60,000). On the other hand,
Iran has done 150 deceased donors and 0 live donors since 1993; Turkey has done 696
deceased donors and 0 living donors since 1988; and Saudi Arabia has done 341 deceased
donors and 208 live donors since 1990. There is great variation across the Middle East in
religious and cultural factors as well as liver transplantation practices. It is unknown
whether or not health insurance benefits play a role as well.
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Paying for Liver Transplant
Many people believe that transplantation is an extravagance that we would be
better off to use our limited health care dollars for primaiy care and preventive care.
Both Drs. Kam and Trotter were queried on this topic. Dr. Kams response was clear,
Transplant has brought so many advances to medicine... it has stimulated research.
He also notes that benefits extend beyond the benefit both to medicine generally and
specifically to the transplant recipient. Philosophically, how does one calculate the
benefit of saving a human life? Is the persons value solely based on money earned and
consumer goods purchased in a lifetime? While these things are important, the value of
being available to raise children or contribute to society in other, noncommercial ways,
shouldnt be ignored.
Dr. Trotter takes a slightly different view. Individuals who are unable to afford
health insurance and consequently immunosuppression medications, along with the costs
of maintaining a healthy lifestyle and complying with follow-up care (labs and
procedures as needed), may not be well-served by the transplant. In a setting of severely
limited resources, the requirements of follow-up care would become a significant
financial burden. Some patients, who find themselves in this situation, may sacrifice
immunosupression medications in order to pay the rent The sacrifice could well lead to
a rejection episode and consequent hospitalization, or even death. The long range benefit
to such patients is debatable.
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Transplantation is costly. Ms. Polsky explains that, while she cant pin down the
costs of a transplant, the average charge is between $350,000 and $400,000. Average
charges for post transplant care during the first year after a transplant are between
$80,000 and $100,000, excluding the charges for medication. Medications are costly as
well, as much as $2000 per month in some cases. Without health insurance, these costs
are well outside the reach of most people.
It is important to note that average charges do not bear any resemblance to the
actual payment (reimbursement) for transplant services. The intervening factor is the
transplant contract. Ms. Polsky is responsible for negotiating contracts with health
insurance plans for both University of Colorado Hospital and University Physicians, Inc.
The process is a complicated and exacting one.
The first step is to calculate anticipated charges factoring in both direct costs (the
surgery, the surgeon, hospitalization, labs and procedures, etc.) and indirect costs
(overhead, salaries of nurses, social workers, support staff, financial counselors, etc.).
Organ acquisition costs are not discounted and must be factored into the calculation. The
recovery of a single liver costs $26,000. This fee includes the costs of Operating Room
time (billed by the minute), surgical staff, the battery of blood tests and procedures that
must be performed to determine if the organ is suitable for donation, labs tests run by
outside vendors (such as Bonfils Blood Bank), and transportation costs (sometimes
involving a jet airplane due to the strictly limited time allowed to pass between recovery
and transplant. Both direct and indirect costs from an average year are considered.
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Generally, 1% of indirect costs and 100% of direct costs are divided by the number of
patients transplanted that year, arriving at a projected amount which must be reimbursed
to just cover costs. Next, a floor and stop loss must be determined. The floor means
that UCH will never get less than x% of hospital and doctor charges. The stop loss
means that, if charges exceed $x, then UCH is reimbursed x% above that amount.
Contracts are then negotiated with each carrier or third party administrator
(TP A). Our program outcomes, the years of practice by transplant surgeons and
hepatologists, and the volume of liver transplants performed per year are vital
components of the negotiation. The better our outcomes, the more experienced our
physicians and surgeons, and the more liver transplants performed each year, the better
our bargaining position. Outcomes are available through the Scientific Registry for
Transplant (SRTR), a repository of statistical transplant data from all centers in the USA,
and through UNOS reporting. The outcomes of various centers can be compared using
these tools. Some health plans will designate a particular transplant center as a Center of
Excellence or an Institute of Quality. These designations are merely marketing devices
and dont impact contracting in any significant way.
In some cases, the contracting entity is a transplant network negotiating on behalf
of member insurance plans or groups. The United Resource Network, Lifesource, and
Aetna National Transplant are examples of such entities. Such entities charge their
members a substantial access fee, based on actuarial estimates, to participate in the
negotiated contract. The amount of the access fee is unknown. These contracting entities
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receive the bills from UCH and UPI, reprice them in accordance with the boundaries of
the contract, and pass the repriced or discounted bills on to the health plan for payment.
In addition, the contracting entity comes to the bargaining table with ideas of their own
about the floor and the stop loss, for example. Contracting can be an arduous process.
Occasionally, a small, self-funded group plan will have an employee or
dependent who requires a liver transplant. In this case, an individual contract is
negotiated between UCH and UPI, represented by Ms. Polsky, and the health plan on that
patients behalf. The process is similar to the process described above. Payment is made
directly to UCH and UPI by the health plan, however, and not passed through a third
party administrator.
Contracts are compartmentalized into phases: evaluation, listing, medical
management while on the list, the transplant, post transplant care (both out-patient and in-
patient). Post transplant care is defined normally as a period ending one year after
discharge from the hospital after the transplant although there is some variation among
contracts. If the patient is in-patient at the time of the transplant, it may be difficult to
discern where one phase of the contract ends and the next begins. If the patient requires
retransplant during the initial transplant admission, determination ofphases must again
be made. If retransplant occurs after discharge, the whole process begins again. Careful
auditing of each case is required to assure that the contracts are honored and UCH and
UPI are paid appropriately.
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Specific requirements for timely filing of charges by UCH and UPI, and timely
payment by the carrier are built into every contract. In addition, the contract contains
specific guidelines for a formalized audit, if requested by the carrier or third party
administrator. Most contracts have a 2-year term. At the end of the contract, it would be
renegotiated as outlined above. UCH and UPI prefer this arrangement to an evergreen
contract that continually self-renews on an on-going basis. Conditions change, costs
change, and contracts must keep up with the changes.
Occasionally, a patient without insurance but with significant financial means
presents, needing a liver transplant. In this case, a deposit policy is in place. There is
usually some element of negotiation involved. There are various methods of payment
that can be accepted. These arrangements must be made in advance of transplantation
taking place.
Medicare patients are handled differently. There is no contract here, rather
payment is made based on a Diagnosis Related Group (DRG), essentially a price list for
services that reflects the complexity of care required for the diagnosis group. UCH has
an accounting device called Organ Acquisition. Charges that relate to evaluation (pre-
transplant testing) and maintenance of the patient on the list, as well as all charges related
to live donors, are accumulated in the Organ Acquisition account and itemized in the
Medicare Cost Report. In determining reimbursement, Medicare considers the total
number of patients at UCH and the percentage of these that are Medicare patients. It also
considers the ratio of costs to charges and reimburses UCH annually accordingly. The
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percentage of reimbursement is different for labs, medications and procedures. It is
based on revenue codes, a device used in the hospital setting for identifying certain
specific categories of medical services. The total payment from Medicare for a liver
transplant is $160,000 (including pre-transplant testing, lab testing, the surgery and
postoperative care). The surgeon is paid approximately $4600. For Medicaid patients,
payment for a liver transplant is approximately $117,000 and for the surgeon
approximately $7700. Per Ms. Polsky, ... the surgeon is reimbursed by Medicare
approximately 18% of billed charges and by Medicaid approximately 30% of billed
charges. It should be noted that Medicare reimbursement is typically in the 33% range
for most medical services. The low reimbursement for transplant surgeons is an
aberration.
All of this assumes that UCH continues to be a Medicare Provider meaning that
the facility must meet Medicares standards for medical and fiduciary practice. A facility
that is found guilty of Medicare fraud (for improper billing for Medicare patients) could
lose standing as a Medicare provider and, consequently, lose the ability to take care of
any Medicare patient. This is a strong incentive to avoid fraudulent billing practices.
Medical standards at facilities are assured through an annual visit from the Joint
Commission on the Accreditation of Hospitals (JCAHO). A very thorough perusal of
hospital facilities is made and practices are examined. This assessment is mandatory if
Medicare provider status is to be preserved.
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Financial aspects of transplantation are extremely important, given the costs
involved. Any hospital could be put out of business if this aspect is not handled properly.
The financial health of both the facility and physicians must be addressed for the benefit
of all patients, not just transplant patients. We must keep the ship afloat. The
infrastructure required to provide transplant services has become very complex. The
health care environment itself has become more complex.
Apparently, University of Colorado Hospital has successfully confronted
increasing complexity with increasing efficiency as evidenced by the continuing ability to
transplant patients.
Institutional Issues
Ms. Biglin has been a prime mover in improving the position of the Division of
Transplant Surgery. While her orientation is primarily a business one, she is also a strong
advocate for high levels of performance in all aspects of care. She often says that, Every
person involved in the transplant business has to be an expert. This statement is
certainly true. It is true for medical providers, it is true for the business people, and for
everyone in between.
Ms. Biglin has been with the Division for nine years. In that time, she has seen
increasing complexity in the health environment Contracts have become more complex.
Negotiations have become more complex. UCH and UPI have responded in kind by
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becoming more knowledgeable about the process and more assertive in negotiating
advantageous contracts.
All transplant programs (Heart, Lung, Liver, Kidney and Hepatology) are
currently housed at the 9th & Colorado Blvd. Campus. In May of2007, the transplant
programs will begin a move to the Fitzsimons Campus. A new Transplant Center has
been designed to the Teams specifications on the 7th floor of the Anschutz Out-Patient
Pavilion. The move will be complete by the middle of June when all in-patients on the
Transplant Unit at the 9th & Colorado campus move to the Anschutz In-Patient Pavilion.
This has been an enormous undertaking, requiring countless planning meetings.
Participants have been forced to examine current processes and then attempt to anticipate
what will be required in the new venue.
Ms. Bigiin has played an important role in this planning process. In addition, she
has hopes for the future improvements that will be made possible by a consolidation of
effort in all phases of transplant. She speaks of dotted-line accountabilities in which
ancillary services (such as transplant billing), though not physically housed in the
Transplant Center, will be accountable to a centralized governing board of transplant
providers. Regular meetings would be held in which reimbursement and adjustments
(write-offs) would be reviewed. The transplant billers would be directly accountable in
this way. Likewise, contracting people would be accountable to the governing board
rather than only the hospital. Always the realist, Ms. Bigiin knows that these
improvements will not happen at University of Colorado Hospital any time soon
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because of the difficulties inherent in the system, not the least of which is finding space
in a clinical setting for financial people. In addition, the hospital bureaucracy has
solidified in ways that preclude making adjustments which, while eminently logical and
appropriate, cant be brought into being not unlike any other big bureaucratic system.
For the time being, there is more involvement, collaboration and fiscal oversight
between the division and both hospital and physician contracting entities. This is a vast
improvement over days past. When asked if the Transplant Team was flexible enough to
adapt to changes in the environment without sacrificing quality standards, Ms. Biglin
responded with an unqualified, Yes. While there is a lack of local competition, it is
still necessary to be sure that the team remains competitive. This aspect is reviewed in a
continuous, ongoing fashion. Ms. Biglin notes, Being sensitive to changes in the
environment allows for prompt responses.
There is a curious disconnect between University of Colorado Hospital (UCH),
the Health Sciences Center (HSC), and University Physicians, Inc (UPI)- Certainly, each
organization has a different culture, function and scope and, as such, must remain an
individual entity, separate from the others. Unfortunately, this disconnect has lead to
dysfunction in the past. For example, when the hospital brings a new computer
application on board, UPI users may have difficulty getting the application loaded on
their computers (machines that fall under the Health Sciences Center domain), and even
getting trained on the application may be a challenge. Ms. Biglin hopes that, since all
personnel in the Transplant Center (though a mixture of UCH and UPI employees) will
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be primarily involved in transplant, and the fact that transplant is a unique world unto
itself, there will be a unifying theme, similar concerns and problems. This should
minimize clashes that may occur within the center.
When Dr. Kam was asked what institutional improvements he would like to see,
he indicated that improvement in availability of ancillary services would be appreciated.
Transplant surgery is available every day, at any time. He thinks the other services
should operate that way as well. In addition he would like to see clinical efficiency
throughout the system that is as good as in the best private systems. It doesnt seem that
he expects to see either of these materialize any time soon, again reflecting the
solidification of both the UCH and UPI bureaucracies.
While the new space at Fitzsimons will be an upgrade from the current facility, it
remains to be seen what problems will arise and benefits accrue as a result of being in the
new facility. We are cautiously hopeful.
Ethical Considerations
In past years, the primary ethical discussion in transplantation revolved around
living liver donation. In violation of the tenets of medical school education, Primum
non nocere or First, do no harm (http://en.wikipedia.org/wiki/primum non nocere,
3/14/07), an otherwise healthy patient is subjected to a potentially life-threatening,
major abdominal surgery and removal of 60% of the liver. It is now believed that, with
careful informed consent and providing potential donors with multiple opportunities to
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escape donation if they wish (without losing face), the donor elects to accept risk in the
interest of saving the life of a loved-one.
Currently, there are two hot ethical topics. The first involves implementation of
financial incentives for organ donation, aspects of which have already been discussed
under the section, Increasing the Donor Pool. There is no doubt that a shortfall exists
between those waiting on the list for a liver and the organs available for transplantation.
Approximately 1800 liver patients die eveiy year while waiting for a suitable liver.
Opponents fear that incentives or compensation (no matter what form these strategies
take) will result in commodification of the human body organs being bought and sold
like cabbages or televisions. Proponents feel that it is fundamentally unfair that donor
families are the only ones who do not benefit directly (profit) in some way by the act of
donation. Recipients get an organ. OPOs get a fee as do hospitals and physicians. Social
workers, transplant coordinators and support staff get a salary. The donor family gets
nothing concrete. Without meaning to minimize its value, their only benefit is having
some good come out of their loss and the sense of a good deed done (Nelson, et al. 1993,
on-line).
While members of the Liver Transplant Team are strongly opposed to direct
payments between recipients and donors, they are also strongly in favor of compensation
alternatives: payment of funeral costs, college education for the donors children, tax
credits, lifelong health insurance for the family, etc. Preferential plans such as those
offered by Lifesharers.com and Match.com, where membership (at an annual fee) and
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promised organ donation provides preferential treatment later on if transplant is needed
are not viewed as being realistic and, therefore, not useful.
Whatever die resolution, if compensation is to be realized intervention by
legislative bodies will be required to amend NOTA. Transplant recipients who are also
politically active could bring about significant change in this area.
The last ethical issue involves the execution of prisoners to acquire organs for
transplantation. This practice has been prevalent in China for many years, not only as a
means of obtaining organs but also as a means of social control. China claims that the
prisoners have given consent for their organs to be used, a fact that is questioned by
American transplant physicians since prisoners in die United States do not have the right
to give informed consent by law. In any case, the practice is widely denounced by the
transplant community. Dr. Liu Zedong (Director of Transplantation at Jinan Central
Hospital and University, Jinan, China) attended the Controversies in Transplantation
meeting in March, 2007, and presented recent developments in Chinas transplant
programs.
China is second to the United States in the number of transplants done. From
1993 to 2004, 46,000 kidney transplants and 1845 liver transplant have been performed.
In 2005, 3,500 liver transplants were performed. According to Dr. John Fung (Director
of Transplant Center, Cleveland Clinic Foundation, Cleveland, Ohio), there is also a
concern that poor people are being used as paid donors to benefit the wealthy who can
afford transplant. Since 5.6% of Chinas GDP goes to health care, it doesnt seem likely
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that insurance plans are available to the general public and that transplantation is a widely
available benefit. Dr. Liu notes that there is a concerted effort in China to increase donor
awareness, increase the use of living donors, and increase brain death donation. Amid
protests from around the world over execution of prisoners for transplantation purposes,
and because the worldwide transplant community is a relatively small one, China is
beginning to use live donors more and more. So far, 70 live donor liver transplants have
been performed.
Another phenomenon that is peculiar to China is known as transplant tourism,
where patients with sufficient financial resources travel to China for an organ transplant.
They then return to their home countries for post transplant care. Approximately 10% of
the transplants done in recent years have been on foreign nationals instead of Chinese
citizens.
Two important steps toward reform were taken in 2006. First, a law was passed
outlawing the sales of organs. Second, a law was passed restricting foreign nationals
from going to China for transplantation.
Since China is a growing economic force in the world, it would seem likely that
worldwide disapproval of some practices might lead to economic sanctions being
imposed by individuals or countries. It would also seem likely that the Chinese
government would prefer to avoid this situation, particularly in anticipation of their
hosting the Olympics next year.
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In a recent article reported in the Toronto Star, it is learned that South Carolina
lawmakers are considering a bill that proposes a strategy for expanding organ donation in
the state. It is proposed that certain inmates in South Carolina prisons could reduce their
prison sentence by 180 days in exchange for living donation of a kidney if the measure is
adopted (http://www.thestar.com/News/article/189846. 3-20-07). Charges generated
surrounding care of the donor would be paid by the recipient and possibly charitable
groups. This would be strictly an altruistic donation and for kidneys only at this time.
Opponents note that any incentive given in exchange for an organ donation would be
against the law. It will be interesting to see how this story evolves.
Ethical issues in the transplant community spark lively, and sometimes heated,
debate. Over time, conditions change and minds change. What once seemed a terrible
practice moves into the mainstream until it becomes the norm. When Dr. Star/.l first
started laying the groundwork for kidney and liver transplants in the late 1950's, and then
performing the procedures, it was against the medical norms of the times. Much has
changed since then. Transplant, while still somewhat exotic, is practically mainstream
medicine today.
Conditions change... Minds change ...
Involvement of Drug Companies in Transplantation
From March 9-11,2007, the 14th annual meeting on Liver and Kidney
Transplantation, Controversies in Transplantation, was held in Breckenridge, Colorado.
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The meeting is organized by Dr. KanTs administrative assistant, Jody Mandic. The
meeting is well attended and well run. For the fourteenth year in a row, physicians and
surgeons from around the world, nurses, transplant coordinators, and pharmacists gather
to discuss liver and kidney transplantation. As the name of the meeting suggests,
controversial ideas are presented. The meeting is sponsored by various pharmaceutical
and medical equipment companies who are active in the transplant world. Much is
learned at these meetings. New ideas, new techniques, new medications, new strategies
are presented and examined all with the ultimate goal of improving the care we provide
to our patients. In a world where technology is rapidly expanding and the tools available
in health care are increasing, it is incumbent upon health care providers to stay current.
Such meetings make this possible.
When asked if he felt that such contributions compromised a transplant centers
autonomy in any way, Dr. Kam responded that there would not be a problem provided we
use contributions to discuss and promote patient needs. In the end, for him, patient
needs trump all other concerns.
If we could change the Transplant Team...
Most of the individuals interviewed were asked, If you could change the way
the Transplant Team functions, what would you change? There were no surprises in the
responses. Of course, one must allow for occasional difficulties that arise when any large
number of high-performing, strong personalities are engaged in a collaborative enterprise.
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Team members share a desire to see more patients being transplanted. Dr. Kam
would like to see a program of compensation for organ donors put into place. In his
mind, the key to eveiything is having the availability of viable organs for those patients
on our Waiting List dying at the rate of about one patient per week.
Ms. Biglin wishes for a Transplant Center where all the various pieces of the
program are functional and accountable in a unified way. In the meanwhile, she
acknowledges that progress is being made. She also hopes for a smooth transition to the
Transplant Center at the Fitzsimons Campus.
Mr. Brackett wishes that all of the transplant programs fully utilize the
Transplant Database as does the Liver Transplant Team. In the future, he anticipates the
addition of a new, dedicated server for the database. He envisions a future in which
outside physicians can assist with test scheduling of evaluation patients via a physician
referral web page. This would be beneficial to patients and providers alike, providing a
tool in which a patients referring physician can be truly involved in the evaluation
process.
There are structural problems that are proving difficult to solve. Hepatology
needs more nurse case managers and more administrative support. All concerned are
aware of the problem and are working on it. Hopefully, they wont be short-staffed for
long. Each group, however, eventually becomes short-staffed as more and more patients
are evaluated and transplanted. This will be an ongoing challenge for the Transplant
Team a natural outcome of their success.
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