Position Statement on Reform of Organ Procurement Organization (OPO) Metrics

July 7, 2019
National Kidney Foundation Position
The National Kidney Foundation (NKF) is committed to increasing the number of kidney transplants. We acknowledge the challenging and lifesaving work that organ procurement organizations (OPOs) perform to acquire organs for transplant. However, we are concerned that the current OPO donation and yield metrics are not maximizing the recovery and utilization of organs.  
NKF supports a revised OPO donation metric that does not rely on self-reported data, accurately accounts for the pool of potential donors, and provides data which can be used to benchmark and compare OPOs.  Patients want to better understand OPO performance and how that performance translates into reduced wait times and an increased likelihood of successful transplant.
NKF supports a revised OPO yield metric that has dual accountability between OPOs and transplant centers. We believe a dual accountability metric is important to ensure that as many organs as possible, including less than perfect organs, are recovered and successfully transplanted.
NKF asserts the importance of ensuring that any new or revised metrics meet the stated patient goals, patients are engaged in the metric development process, and patient perspectives inform the outcome.
Organ Procurement Organizations (OPOs) are organizations subject to the Organ Procurement and Transplantation Network (OPTN) final rule that are responsible for working with donor hospitals to recover organs, tissues, and eyes from deceased donors, coordinating the donation process leading to transplantation, and educating the public to increase participation in the organ donation process. Fifty-eight OPOs serve unique donation service areas (DSAs) across the United States.
Hospitals that receive any federal reimbursement for care provided and all OPOs are accountable to the Centers for Medicare and Medicaid Services (CMS) for their performance in key areas intended to increase the number of organs and tissues available for transplant. Hospitals must report all imminent deaths to OPOs so that they can screen potential donors for organ, tissue, and/or eye donation. Only OPO staff or a designated requester can approach the family of a potential donor for their consent for donation.
OPOs are recertified by CMS every four years. Recertification is based on compliance with three outcome measures that proceed from two metrics: the donation metric (how often deceased patients become potential donors) and the yield metric (how often donated organs are successfully transplanted).
Problem Statement
Given the critical shortage in the availability of organs for transplant, OPOs, as the entities tasked with procuring deceased donor organs, are under growing scrutiny. Reports of low-performing OPOs have highlighted the variability in OPOs’ success at procuring organs and the need for standardized measures that can benchmark OPOs and identify opportunities for performance enhancement. The donation and yield metrics used to evaluate OPO performance have long been recognized as flawed, with much of the discussion focused on the donation metric (the number of organs recovered with the intent to transplant as compared to “eligible deaths”).  The donation metric denominator of “eligible deaths” is self-reported by OPOs, which leads to ambiguous, noncomparable statistics on donor data. The concept of eligible deaths is also widely criticized for failing to include a subset of actual and potential donors, leading to lost opportunities for donation. The yield metric is also imperfect, though currently less controversial.
Policy changes to improve OPO performance by reforming OPO metrics are both ongoing and forthcoming. Legislation seeking improved oversight and accountability of OPOs is expected to be introduced in the Senate shortly. CMS will release new OPO regulations within the next several months.
National Kidney Foundation (NKF) Position Development
NKF’s Transplant Workgroup heard from key stakeholders with the goal of developing an NKF position on OPO metrics and shaping the public policy debate around OPO metric reform. The workgroup discussed several alternative donation metric denominators to eligible death. The workgroup noted the tension between an alternative proposed by Dr. David Goldberg of the Perelman School of Medicine[1] that would better facilitate OPO benchmarking & comparison versus one proposed by the Association of Organ Procurement Organizations (AOPO)[2] that would more accurately capture donor potential, but not address OPO comparison. The workgroup concluded that both goals are important to patients, who want to both better understand OPO performance and how that translates into more successful transplants and expand the pool of potential donors. The workgroup determined that several of the alternative denominators could balance these objectives and declined to take a position on any specific proposal.
The workgroup discussed the yield metric, noting that because the metric is tied to success of the transplant OPOs and transplant centers should have dual accountability for it. The workgroup determined that the oft-cited flaw that the yield metric disincentivizes single-organ donors may be overstated. The workgroup supports development of a dual accountability yield metric.
The workgroup was ultimately supportive of patient centric OPO metric reforms which increase the donor pool, provide objective and standardized data that can be used to understand and improve OPO performance and acknowledge the role of transplant centers in utilizing organs procured by OPOs.
Kidney Disease Facts
In the United States, 37 million adults are estimated to have chronic kidney disease (CKD) – and most aren’t aware of it.  1 in 3 American adults is at risk for CKD.  Risk factors for kidney disease include diabetes, high blood pressure, heart disease, obesity, a family history of kidney failure, and being age 60 or older. People of African American, Hispanic, Native American, Asian or Pacific Islander descent are at increased risk for developing the disease. African Americans are about 3 times more likely than Whites to develop end-stage kidney disease (ESKD or kidney failure). Compared to non-Hispanics, Hispanics are almost 1.3 times more likely to receive a diagnosis of kidney failure.
The National Kidney Foundation (NKF) is the largest, most comprehensive, and longstanding patient-centric organization dedicated to the awareness, prevention, and treatment of kidney disease in the U.S. For more information about NKF, visit www.kidney.org.

[1] Donors per 1,000 inpatient deaths <75 from causes consistent with organ donation
[2] In-hospital deaths, ventilated within one hour of death, under age 71, without contraindications