Author Archives: Tayfun Sonmez

Easing the Kidney Shortage: Wall St. Journal

In the Wall Street Journal on June 17, 2004 in an article title “Easing the Kidney Shortage” in his column CAPITAL, David Wessel writes:

Renal Donors Swap Recipients If Blood Types Don’t Match; Cheating on Priority Lists

June 17, 2004; Page B1

As of noon yesterday, 58,470 people in the U.S. were waiting for a kidney transplant. Most won’t get one this year. There aren’t enough donated kidneys to go around. Surgeons transplanted just 15,129 kidneys last year. Now a band of transplant surgeons and economists are trying to fix that by creating a moneyless market for exchanging kidneys. Most transplanted kidneys come from a person who has died, a supply that grows slowly because of ignorance about the need for donations or grieving relatives’ reluctance. But a kidney taken from a live donor works better, and almost everyone has a spare. As techniques improve for removing healthy kidneys and for suppressing the body’s tendency to reject a transplant, doctors increasingly turn to kidneys from living donors, usually relatives. Last year, 43% of kidneys transplanted in the U.S. came from living donors, up from 28% a decade ago. But a biological barrier often blocks a transplant from a relative. In about a third of all would-be pairs, blood types are incompatible. In others, the sick person has antibodies that can initiate a rejection of the donated organ. It’s heartbreaking “to have the treasure of the live donor and then have that not go forward because of a biological obstacle,” says Massachusetts General Hospital transplant surgeon Francis DelMonico.

Occasionally, transplant centers spot a way out: One New England father with blood type A couldn’t donate a kidney to his daughter with blood type B. So he gave a kidney to a teenager with blood type A, and the teenager’s sister gave a kidney for the man’s daughter. New England’s transplant centers have done six such exchanges. Baltimore’s Johns Hopkins University has done seven.

In the past year, Hopkins also has done two exchanges that involved three transplants each, an undertaking that requires six operating rooms and 60 medical professionals (see diagram2). In New England, Washington, D.C., and elsewhere, would-be donors unable to give a kidney to a loved one instead have given a kidney to a stranger. The loved one, in turn, is rewarded by being moved up on the waiting list for a dead person’s kidney.

Such swaps occur, though, only when the right combination appears or a flurry of e-mails among transplant centers produces the right mix. A highly organized system alerts transplant centers when a dead person’s kidney is available; there isn’t any system for a man who can’t give to, say, his wife, but wants to advertise his willingness to make a swap. Hopkins transplant surgeon Robert Montgomery figures that 2,000 or more people could get transplants each year if there were a national database of such donors.

Transplants are expensive: Johns Hopkins says the cost is roughly $120,000 when everything is included. Medicare usually foots the bill for patients without private insurance, though it doesn’t pay that much. Buying or selling a kidney in the U.S. is illegal.

Donors, recipients and relatives involved in three-way kidney transplant at Johns Hopkins Hospital in Baltimore last year

Lawyers and ethicists, after substantial deliberation, decided a few years ago that kidney swaps like those done in Boston and Baltimore are acceptable. And doctors agree on some simple rules: The donor must travel to the hospital where the recipient is; participants may keep identities private if they choose; all operations in a swap begin simultaneously to avoid anyone backing out halfway through the swap.

While the doctors were working all this out, Harvard economist Alvin Roth, a specialist in designing moneyless markets like the one that matches medical residents to teaching hospitals, was pondering the problem. He proposed to a visiting protégé, Utku Ünver of Istanbul’s Koc University, that the two teach a course using kidneys as an example. Thinking about kidney donors and recipients, it turned out, was similar to thinking about the way colleges allocate dorm rooms, a problem Mr. Ünver and colleagues had studied.

The result was an article published in the Quarterly Journal of Economics last month by the two men and a colleague from Koc, Tayfun Sönmez, that describes how to structure a kidney exchange to identify potential swaps among a large pool of people with rules that make it very hard for anyone to cheat.

Cheating is an issue in transplants. In Chicago, for instance, cardiac doctors have been accused by local prosecutors of overstating the severity of patients’ illnesses to move them up on the priority list for hearts. And rules, such as those that depend on how long one has been waiting for an organ, don’t always anticipate human cleverness; rules had to be changed, for instance, when doctors began to put babies on waiting lists for heart transplants before they were born.

The economists’ premise is simple: Don’t expect anyone to do anything that isn’t in his or her self-interest. As long as a computer can identify the one kidney in the pool that best suits a patient, the system is foolproof, the economists say.

Massachusetts General’s Dr. DelMonico admits to some skepticism when the economists approached him last fall. But the collaboration has blossomed over the past few months. Dr. DelMonico handles the intricacies of forging a consensus among the 14 transplant centers in New England and finding money to support a computerized system to implement the economists’ design.

Harvard tissue-typing specialist Susan Saidman, meanwhile, is working to perfect a computer system to simplify the process of checking to be sure potential recipients don’t have antibodies that could cause them to reject an otherwise suitable donor’s kidney.

The most compelling moment so far came when Dr. Saidman gave the economists details on 45 pairs in which the would-be donor was unable to give a kidney to the intended recipient. Even though each of the 45 had a donor willing to spare a kidney, all were stuck waiting for the right person to die. With swaps involving two kidneys, the economists found, eight transplants were possible. If swaps involving three kidneys were possible, then 11 transplants were possible.

“Easing the Kidney Shortage” (WSJ) June 17, 2004

In the Wall Street Journal on June 17, 2004 in an article title “Easing the Kidney Shortage” in his column CAPITAL, David Wessel writes:

Renal Donors Swap Recipients if Blood Types Don’t Match; Cheating on Priority Lists

June 17, 2004; Page B1

As of noon yesterday, 58,470 people in the U.S. were waiting for a kidney transplant. Most won’t get one this year. There aren’t enough donated kidneys to go around. Surgeons transplanted just 15,129 kidneys last year. Now a band of transplant surgeons and economists are trying to fix that by creating a moneyless market for exchanging kidneys. Most transplanted kidneys come from a person who has died, a supply that grows slowly because of ignorance about the need for donations or grieving relatives’ reluctance. But a kidney taken from a live donor works better, and almost everyone has a spare.

As techniques improve for removing healthy kidneys and for suppressing the body’s tendency to reject a transplant, doctors increasingly turn to kidneys from living donors, usually relatives. Last year, 43% of kidneys transplanted in the U.S. came from living donors, up from 28% a decade ago. But a biological barrier often blocks a transplant from a relative. In about a third of all would-be pairs, blood types are incompatible. In others, the sick person has antibodies that can initiate a rejection of the donated organ. It’s heartbreaking “to have the treasure of the live donor and then have that not go forward because of a biological obstacle,” says Massachusetts General Hospital transplant surgeon Francis DelMonico.

Occasionally, transplant centers spot a way out: One New England father with blood type A couldn’t donate a kidney to his daughter with blood type B. So he gave a kidney to a teenager with blood type A, and the teenager’s sister gave a kidney for the man’s daughter. New England’s transplant centers have done six such exchanges. Baltimore’s Johns Hopkins University has done seven.

In the past year, Hopkins also has done two exchanges that involved three transplants each, an undertaking that requires six operating rooms and 60 medical professionals (see diagram2). In New England,Washington, D.C., and elsewhere, would-be donors unable to give a kidney to a loved one instead have given a kidney to a stranger. The loved one, in turn, is rewarded by being moved up on the waiting list for a dead person’s kidney.

Such swaps occur, though, only when the right combination appears or a flurry of e-mails among transplant centers produces the right mix. A highly organized system alerts transplant centers when a dead person’s kidney is available; there isn’t any system for a man who can’t give to, say, his wife, but wants to advertise his willingness to make a swap. Hopkins transplant surgeon Robert Montgomery figures that 2,000 or more people could get transplants each year if there were a national database of such donors.

Transplants are expensive: Johns Hopkins says the cost is roughly $120,000 when everything is included. Medicare usually foots the bill for patients without private insurance, though it doesn’t pay that much. Buying or selling a kidney in the U.S. is illegal.

Donors, recipients and relatives involved in three-way kidney transplant at Johns Hopkins Hospital in Baltimore last year

Lawyers and ethicists, after substantial deliberation, decided a few years ago that kidney swaps like those done in Boston and Baltimore are acceptable. And doctors agree on some simple rules: The donor must travel to the hospital where the recipient is; participants may keep identities private if they choose; all operations in a swap begin simultaneously to avoid anyone backing out halfway through the swap.

While the doctors were working all this out, Harvard economist Alvin Roth, a specialist in designing moneyless markets like the one that matches medical residents to teaching hospitals, was pondering the problem. He proposed to a visiting protégé, Utku Ünver of Istanbul’s Koc University, that the two teach a course using kidneys as an example. Thinking about kidney donors and recipients, it turned out, was similar to thinking about the way colleges allocate dorm rooms, a problem Mr. Ünver and colleagues had studied.

The result was an article published in the Quarterly Journal of Economics last month by the two men and a colleague from Koc, Tayfun Sönmez, that describes how to structure a kidney exchange to identify potential swaps among a large pool of people with rules that make it very hard for anyone to cheat.

Cheating is an issue in transplants. In Chicago, for instance, cardiac doctors have been accused by local prosecutors of overstating the severity of patients’ illnesses to move them up on the priority list for hearts. And rules, such as those that depend on how long one has been waiting for an organ, don’t always anticipate human cleverness; rules had to be changed, for instance, when doctors began to put babies on waiting lists for heart transplants before they were born.

The economists’ premise is simple: Don’t expect anyone to do anything that isn’t in his or her self-interest. As long as a computer can identify the one kidney in the pool that best suits a patient, the system is foolproof, the economists say.

Massachusetts General’s Dr. DelMonico admits to some skepticism when the economists approached him last fall. But the collaboration has blossomed over the past few months. Dr. DelMonico handles the intricacies of forging a consensus among the 14 transplant centers in New England and finding money to support a computerized system to implement the economists’ design.

Harvard tissue-typing specialist Susan Saidman, meanwhile, is working to perfect a computer system to simplify the process of checking to be sure potential recipients don’t have antibodies that could cause them to reject an otherwise suitable donor’s kidney.

The most compelling moment so far came when Dr. Saidman gave the economists details on 45 pairs in which the would-be donor was unable to give a kidney to the intended recipient. Even though each of the 45 had a donor willing to spare a kidney, all were stuck waiting for the right person to die. With swaps involving two kidneys, the economists found, eight transplants were possible. If swaps involving three kidneys were possible, then 11 transplants were possible.

The Boston Globe Cross-donor system planned for region’s kidney patients (BG) June 5, 2004

The Boston Globe

Cross-donor system planned for region’s kidney patients

By Scott Allen, Globe Staff, June 5, 2004

New England transplant surgeons, working with a Harvard economist, are planning a unique organ-trading system that could ease the shortage of kidneys available for transplant by giving willing donors a strong new incentive to give their kidneys to strangers.

Currently, hundreds or even thousands of potential organ recipients must join a long transplant waiting list even though friends or family members are willing to donate a kidney, because the would-be donors prove to be a poor match with the patient. The new system would take these willing donors and connect them with similarly mismatched donors elsewhere in New England, allowing them to cross-donate kidneys to each other’s friends or loved ones.

Since 2001, New England doctors have performed six of these paired exchanges, including one last year when two women each successfully donated a kidney to the other’s husband at Massachusetts General Hospital. But the idea’s effectiveness is limited by the difficulty of finding well-matched patients and donors.

To overcome this, Harvard economist Alvin Roth developed a new computerized donor tracking system that could allow doctors to arrange scores of exchanges per year in New England alone, over time significantly reducing a regional kidney waiting list that now stands at 2,237. In a limited test of his system, Roth found eight matches from 45 potential donors who had previously been rejected. Applied nationally, Roth believes the system could potentially save thousands of lives.

”This could be quite a substantial increase in the number of live donors,” said Dr. Francis L. Delmonico, medical director of the New England Organ Bank in Boston, which manages the region’s organ supply.

The paired-exchange system appears to be surmounting the ethical concerns that have sunk other ideas for fostering more organ donation. Congress long ago barred financial incentives to encourage donors, but medical ethicists are also concerned about any system that pressures people to undergo a risky operation that does not benefit their own health. Though most organ donors recover fully, an estimated one in 3,000 die and all of them lose their backup kidney in the event they develop kidney disease themselves.

Writing in The New England Journal of Medicine recently, Delmonico argued that organ exchanges can be ”models of altruism” as long as everyone knows the risks and no money is involved. A transplant surgeon at Mass. General, he has proposed Roth’s matching system to the panel of surgeons that sets kidney transplant policy in New England.

”I don’t think that there are any ethical issues” to expanding the number of trades, said Dr. Paul Morrissey of Rhode Island Hospital, chairman of the Renal Transplant Oversight Committee. ”It’s just setting up the mechanism to carry it out.”

Even tough critics such as Dr. Lainie Friedman Ross, medical ethicist at the University of Chicago, agree that the paired-exchange system can be fair. Ross has faulted other approaches for discriminating against one group of patients in favor of another, but she said she’s ”totally in favor” of Roth’s system.

The paired-exchange system comes 50 years after Dr. Joseph Murray carried out the nation’s first kidney transplant at what is now Brigham and Women’s Hospital, using a kidney taken from the patient’s identical twin to avoid organ rejection. Today, in part to antirejection drugs, surgeons can often transplant kidneys between perfect strangers even if the donor’s tissue is a poor match.

As a result, almost a quarter of live donors are not related to the patient who gets their kidney.

Roth estimates that nearly half of willing donors do not donate because their blood type doesn’t match the patient or the patient’s immune system would attack the donated organ, and because there is currently no system for keeping track of rejected donors.

Roth’s system would change that by entering potential donors’ names into a computer database and searching for a match. Long interested in improving the transplant system, Roth has written a detailed paper with two other economists outlining how the system will work.

With the kidney transplant waiting list now up to 61,000 across the country, transplant surgeons and patient groups will be watching the New England experiment closely. Morrissey said the system is sure to save lives, but ”whether it adds 15 transplants a year or 150 remains to be seen.”

In recent years, surgeons have become increasingly desperate for transplant organs, with some even suggesting that people get paid to fill out an organ donor card.

So far, the handful of paired exchanges completed in New England have created happy endings for people who were increasingly hopeless.

For instance, Susanna Polletta of Watertown, Conn., had wanted to donate a kidney to her husband, Rosario, whose kidneys were gradually failing as a result of a long battle with lupus.

But both her blood and tissue types were a complete mismatch for him, so Rosario remained on a transplant waiting list for years, relying on home dialysis to keep his body going.

By chance, Rosario’s doctor at Mass. General, Nina Rubin, was treating another man who had the same problem: Tracy Scott of Chichester, N.H., was languishing on the transplant waiting list even though his wife, Robin, was ready and willing to donate a kidney. Then Rubin discovered that Robin’s kidney was a match for Rosario while Susanna’s matched Tracy’s. ”It was like a miracle,” said Rosario Polletta.

On Feb. 25, 2003, the women donated their kidneys to the two men, and, 15 months later, all four have resumed their normal lives.

”I probably have more energy now than I did when I was 30,” said Polletta, now 47.

Scott Allen can be reached at allen@globe.com. 

© Copyright 2004 The New York Times Company

“Kidney Exchange”

“Kidney Exchange” (joint with Alvin Roth and Utku Ünver), Quarterly Journal of Economics 119-2: 457-488, May 2004. (Also see much detailed NBER working paper version.) [ Abstract ] [ PDF ] [ Policy ImpactMedia

School assignment flaws detailed (BG), September 12, 2003

The Boston Globe

School assignment flaws detailed

Two economists study problem, offer relief

By Gareth Cook, Globe Staff, 9/12/2003

Boston uses a deeply flawed system for assigning students to its public schools, pushing more students out of their top-choice schools than necessary and giving parents a reason to lie about which schools they want, according to a pair of researchers who recently published their findings in a leading economics journal.

A new system, they say, could greatly reduce the anxiety in the city’s annual school-choice process, in which thousands of parents submit lists of their top choices and await the computer-generated decision that will affect the next year to five years of their child’s education.

The researchers found that once the parents submit their lists, they are subject to a poorly designed method of allocating spots in the top schools. By using a different technique, they say, the city could get more students into one of their top-choice schools while also making the system fairer. The alternate technique, which the researchers outline in the paper, could be put in place with relatively simple, inexpensive changes and would not require the city to change any of its broader policies, according to the researchers and other academics who have seen the paper.

“Once all this is known, I don’t see how they can keep the Boston mechanism,” said Turkish economist Tayfun Sonmez, one of the researchers who studied Boston’s system.

For more than two decades, policymakers have devoted enormous amounts of attention to various ways to assign students to schools, sparking philosophical debates, charges of racial and economic discrimination, and tangled court battles — all of which have played out with particular drama in Boston. But the authors say their work, which also examined districts in Columbus, Minneapolis, and Seattle, is the first rigorous examination of how best to do the actual matching once the policy is decided.

The research has broader implications as well. If more parents were happier with their school assignments, it would help keep them from fleeing for the suburbs and bolster the fortunes of the school district — and the city. Officials with the Boston public schools and the Boston School Committee readily acknowledge that parents are frustrated with the current system, and officials said at a School Committee meeting this week that they would make changing the system a priority. They have not yet considered the method suggested by the economists.

“For every parent who feels frustrated about a policy, there is always a parent who will feel frustrated about an alternative,” said Christopher M. Horan, chief of staff for the Boston public schools. Horan said he was intrigued by the economists’ work and considered their suggestion a serious alternative.

In Boston, most students have to apply to get into kindergarten, first grade, sixth grade, and ninth grade. All students are given a priority ranking at each school, based on whether they have a sibling there, whether they live within walking distance, and a lottery number. And all parents rank the schools they would like their children to attend.

To begin, each school considers all the students who ranked it number one, and gives out seats in order of the student’s priority at that school. Then, each school that still has room considers all the students who ranked it number two, and again gives out seats in order of student priority. This process continues until all the students are assigned a spot or no more schools are left on a student’s list — in which case the student is “unassigned” and ends up at a school that still has an empty spot.

The problem, as parents quickly figure out, is that many of the best schools fill up in the first round, so students who don’t get into their first choice can find themselves crowded out of all their top choices.

“It is crazy,” said Kathy Bear, a West Roxbury mother whose 5-year-old daughter, Kaitlyn, didn’t get any of her top choices for kindergarten, and was assigned to a distant, troubled school in Dorchester.

Parents who learn how the system works begin to “game” it by lying about their top choices, ranking a less desirable school first in the hope that they’ll have a better chance of landing a spot. Now that she understands the system better, Bear says she will be more strategic in her selections for first grade.

Another problem, according to the economists, is that the Boston matching technique leads to situations where a student doesn’t get into a school even though he or she is higher on the school’s priority list than a student who did. This happens because as soon as a school fills up, it no longer considers any more applicants, no matter how high the student might be on the priority list.

A better alternative, said the researchers in the June issue of the American Economic Review, is a system similar to the national “matching” process used to assign residencies to medical students.

This system starts the same way as the method now used in Boston, with each school considering students who rank it number one and accepting them in order of their priority at the school. The critical difference, said Atila Abdulkadiroglu, a co-author of the study and an assistant professor of economics at Columbia University, is that this initial assignment is only temporary.

In the next round, students who didn’t get into their first choice are allowed to apply to their second choice. That school then considers these students, along with all the students temporarily assigned to it, and gives out all of its seats in order of the students’ priority. This process repeats, with any unassigned students applying to the next school on their list, and getting in if there is room — or bumping other students if they are higher on the priority list.

When all students have been assigned, the process ends, and the assignments become final.

This method has several advantages, according to the study. First, the best strategy for parents is always to list the schools in their true order of preference. The technique also eliminates all cases of a student losing a spot to a lower-priority classmate.

An experiment run by Sonmez, who is an associate professor of economics at Koc University in Istanbul, and University of Michigan economist Yan Chen also indicates that the method is likely to make more students happier with their assignment. In the experiment, which used 36 students vying for seven schools, most students wound up at a school that was slightly higher on their list of preferences.

Of course, no new system can create more seats at the most sought-after schools. But all parents interviewed by the Globe said that it would be a huge relief simply to write a truthful answer to the question: What school do you want?

“A lot of the alienation some parents have toward the choice system is solely attributable to the alienation of not making your first choice your first choice,” said Neil Sullivan, the father of four children who have attended Boston public schools.

Gareth Cook can be reached at cook@globe.com.

© Copyright 2003 Globe Newspaper Company.

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