Update: Steve Jobs Resigns: Reposting an Old Post Titled: Steve Jobs' Health, Apple Computer, and Organ Transplantation Possibilities

Steve Jobs has just resigned as CEO of Apple Computer. I wish him a speedy and complete recovery from his illness. Below, I am reposting an article I wrote from earlier this year where I suggested a way to increase organs available for transplantation - by encouraging coworkers (in addition to family, friends, and people who worship together at their given Congregations) to donate organs to their fellow coworkers. Are their any Corporate Health Promotion/Wellness Managers who aren't afraid to make waves who would like to champion this idea in their companies? If they look at their costs for paying claims for employees with ESRD/kidney failure who are on dialysis, they certainly should be paying attention.
The original post from Monday, January 24, 2011, is found below:

You probably have heard about Steve Jobs, CEO of Apple, taking a medical leave of absence so that he can focus on his health. Here is the press release. Previously, he has battled pancreatic cancer and undergone a liver transplant.

I wish Steve Jobs all the best and a quick and complete recovery and respect his right to privacy.

I hope Apple champions an intra-company live donor organ donation program whether Steve Jobs is currently in need of a transplant or not because this can bring a revolution to the world or organ transplantation. Corporations like Apple pay towards their employees health insurance costs so they have an economic incentive to keep their employees as healthy as possible. Also, the good-will created by saving and improving the quality of life of their employees is priceless. And it may just contribute towards saving the life of their CEO, Steve Jobs.

I think that an astute Medical Coordinator or Benefits Manager at Apple may want to seize on the opportunity created by the Steve Jobs health situation and implement a corporate initiative to encourage live donor donations from healthy Apple employees to other Apple employees in need of transplants (FYI - therefore, this would work for kidney donations, bone marrow donations, and partial liver donations, depending on transplant center policy.)
Three previous blog posts linked to here, here, and here discuss various statutory laws that decrease the ability to increase the quantity of organs available for transplantion along with a few of my ideas to improve the situation including intra-company live donor donation programs.

A Poorly Designed Government Progam: Medicare (non)Coverage to Create an AV Fistula for Hemodialysis Access: A Case Study

While the U.S. government should be commended for offering universal health coverage for people with ESRD who require dialysis due to kidney failure, the Medicare program could be designed in a more efficient manner to promote increased life expectancy while saving the government money as well (in other words, have cake and eat it too.)

I want to deal with just one point to bring out this point. People who undergo hemodialysis who have vascular access points with AV Fisutulas have lower mortality rate compared to people with catheters. They also have decreased costs related to their treatment. (For examples of articles that support these suppositions, see here and here.

Moreover, Medicare's ESRD coverage does not cover the surgical procedure to create an AV Fistula before dialysis begins even though this correlates with lowered mortality decreased costs. See here for Medicares description of benefits for people with ESRD. The pertinent passage is excerpted here: "Important: Medicare won’t cover surgery or other services needed to prepare for dialysis (such as surgery for a blood access [fistula]) before Medicare coverage begins. However, if you complete home dialysis training, your Medicare coverage will start the month you begin regular dialysis, and these services could be covered." (See pp. 11-12 of the link provided above for a fuller explanation.)

Here is the bottom line. Medicare for people with ESRD should cover the costs associated with creating AV Fistulas for all people who require dialysis because this correlates with super clinical outcomes for the people undergoing dialysis (which leads to a lower mortality rate) while also resulting in substantially lower costs compared to people with catheter access.

Ethical Dilemnas in Directed Kidney Donations

Should a person be able to donate his or her kidney to whomever they prefer, or should all kidneys go to the next person on the waiting list?

This is a major ethical dilemma. Basically, with one possible caveat, I feel that a person should be able to direct their kidney donation to whomever they see fit. I explain my opinion fully below.

Basically, Douglas Hanto, M.D., a Harvard Medical School physician, is quoted to have said “Organs should go to the person who needs them the most, not to people because they are members of a club.” See Dr. Sally Satel's article about one example of Dr. Hanto's action to try to stop directed kidney donation
here.

Robert F. Hickey, Ph.D. is a big advocate of live donor kidney donation. Dr. Hickey's life was saved by a live donor donation and he zealously advocates for the right of people to direct their live donor organ donation. He debated Dr. Hanto on this topic recently at Harvard University.

Robert F. Hickey asked me about my reaction to a situation that was raised at the debate at Harvard. A certain Rabbi who was in attendance said that he advocates for his congregants to donate their organs [exclusively] to other Jews and (I think) to only accept organs from other Jews. Below is my response to the Rabbi's approach.

"This is what I feel about a Jew, or any other segment of the population directing their donation to their own group. While I feel that their motives may not be completely pure, I care about pragmatic results, not some theoretical morality or utopian concept of altruism. If a Rabbi encourages his congregants to donate organs only to other Jews, I feel he is doing a morally just thing anyways b/c Jews are on the waiting list like everyone else so if he encourages his congregants to give directed donations and thereby increasing the pool of organs available for transplantation, there will be a net gain in organs available for transplantation and therefore it will, in final analysis, help Jew and non-Jew alike by that Rabbi encouraging his congregants to donate their organs to Jews."
"Now, a morally troubled outgrowth from such an approach that may arise would be if there was a non-Jew on the waiting list who would certainly die today without the transplant and a Jew who can still live for a while as he awaits a transplant. I would recommend in that situation to give the organ to the non-Jew (pay the organ forward) and then give the next organ that becomes available on the waiting list to the Jewish person on the waiting list."
"Besides for these reasons, I believe that the Rabbi can legitimize his approach from a personal autonomy/libertarian perspective as well."
"Personally, though, I feel the best thing to do would be to take a different approach. I think that the Rabbi may be misguided because his approach can be interpreted with a xenophobic connotation so I think he would be better off to teach his congregants the economics lesson I shared above so that his congregants will understand that by donating organ, they will help everyone on the waiting list, which will definitionally move all of the Jews on the list closer to getting their transplants as well."

I do think, however, that people will tend to donate organs in greater numbers for people they fell a greater kinship for (like family, friends, coworkers, etc.) so from a behavioral economics perspective, there would probably be an increased number of organs available for transplantation if we encouraged more people to give directed organ donations to people they are close with socially. This would, in final analysis, cause more lives to be saved so I think the Rabbi is doing a positive thing - saving human life.

Implanted Windpipe: Exciting New Technology in the Field of Transplantation!

Check out this Wall Street Journal article linked to here titled, "Lab-Made Trachea Saves Man," which discusses how Swedish physicians transplanted an artificial windpipe lined with the man's own stemcells into a man who was close to death because of a large tumor and now is doing well after receiving the transplant just a few weeks ago on June, 9th. There is no sign of rejection.

This is very important to the field of transplantation in general because this is the first time a windpipe has been successfully transplanted without it coming from a cadaver, or a deceased person. Therefore, this renews hope for other artificial tissues and organs to be successfully transplanted into the human body, and thus, hopefully saving many lives.

Also, this leads me to muse about possible (but unknown practical applicability)of covering donated organs and tissues with the patients own stem cells to lower the chance of the body rejecting the donated organ or tissue. This issue is briefly discussed in a Bloomberg article linked to here about this first artificially made windpipe successfully implanted into a human.

This is an exciting new frontier in the field of transplantation. In fact, we might call this the field of implantation because organs are only being implanted, not transplanted because the windpipe was not taken from a human donor.

ESRD Disease Management: Is it Posssible?

The Centers for Medicare and Medicaid Services approved 3 demonstrations projects to study health outcomes along with and economic costs of health management for ESRD patients who were enrolled in these projects (the intervention cohort) compared to populations that were not enrolled in the demo projects (the other cohort). The Evaluation report for the first 3 years of the 5 years demonstration projects in its entirety is found here.
The results were mixed - both in terms of health outcomes and cost savings.

The question is does disease management not work for ESRD populations or was there something wrong with the demo intervention designs (study design error) which caused these results?

I hope and believe that ESRD health management interventions can be designed to improve health outcomes for patients and also be (at least) budget neutral.

Practices from a country such as Italy which has much better ESRD health outcomes (See an older post here where this is discussed) should be used here in the U.S. to improves our ESRD health outcomes.

Also, we can study physicians and medical centers in the U.S. who have better than expected health outcomes with their ESRD populations and transfer their practices and protocols to the rest of the healthcare professionals who treat ESRD populations so that a ESRD health management intervention can designed which imoroves both the life expectancy and quality of life of the ESRD population in the U.S.

Lecture Delivered to College Statistics Class on ESRD: Rational Decision Making Model

This is a handout I gave out to an under-grad stats class (where I was a guest lecturer) where I attempted to use a real life situation to impress upon the students the importance of statistics. I then went through six published journal articles relating to this topic to show them how to make a rational decision based on the current literature and statistics available on ESRD to show them how to come to an "evidence based" decision.

Statistics: So What?
Case Study for Kidney Failure Treatment Options Using Statistics as a Guide
Presenter: Eli Lazovsky, MPH
Date: June 14, 2011–06–14
For: HTC Statistics Class
You are advising a friend who has ESRD/Kidney Failure about his/her treatment options. What would you suggest to them as a rational course of action. Remember, there is not necessarily only 1 correct option. Be able to back up (using statistics) whatever you decide to advise your friend. Your friend isn’t so proficient in statistics so (s)he is relying on what you learned in your statistics class to help out.
What is your recommendation to your friend. Focus on what decision correlates with the following goal: Increase Life Expectancy

Diagnosis: ESRD
Treatment Options:
A. do nothing
B. dialysis
C. transplant

B. Dialysis
1. hemodialysis
2. peritoneal dialysis
Type of Access Point for the hemodialysis
1. AVF
2. AGF
3. Catheter
Frequency of Hemodialysis
1. 3 times a week
2. 6 times a week
C. Transplant
1. Before starting dialysis
2. After starting dialysis
Status of Organ Donor
1. Deceased Donor/Cadaver Organ
2. Live Donor
Type of Organ
1. Ideal Organ
2. Marginal Organ

Treatment Modalities for ESRD Patients: How to Increase Life Expectancy

A person who has kidney failure, or ESRD, should be cognizant that the choices s(he) and their physician make regarding their care will effect their life expectancy.

For example, a study comparing Dialysis treatment in Italy and the U.S. points out that in 2006, the annual mortality rate for people with ESRD in Italy was 11.2+/-.6 compared to 24% in the U.S. A link to the abstract of the article can be found here.
The authors write, in part, that "[t]he following may explain the low mortality for ESRD patients in Italy: low prevalence of diabetes, high use of AV fistulae, delivery of care by nephrologists beginning in pre-ESRD stages, their involvement in placement of dialysis vascular access, and their physical presence requirement during dialysis sessions."

Keep in mind, as of 2006, only 38.6% of dialysis patients had AV fistulas compared to approximately 82% of dialysis patients in Italy (figures taken from the study cited above). Recent data is much more encouraging. As of December 2010, in the U.S., 57.5% of hemodialysis patients had AV Fistulas. See here.

AV fistulas are associated with lower infection rates compare to people with AV grafts and thus better long term outcomes for the patient.

A Veterans Administration study linked to here also found that people on hemodialysis who had AV fistulas lived on average about 3 months longer compared to people with AV grafts.

The bottom line is by studying the various manners of treatment for ESRD both domestically and internationally, ESRD best-practices guidelines can be fashioned to increase the life expectancy and the quality of life for people on dialysis.