By Michael Smith, North American Correspondent, MedPage Today
Published: January 17, 2011
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine,
Harvard Medical School, Boston.
After a rare, high-profile case of HIV transmission through organ transplant, nearly a third of surgeons changed their practice, researchers reported.
But the most common change was to avoid the use of high-risk donors, rather than to institute better ways of detecting the virus before transplant, according to Dorry Segev, MD, PhD, and colleagues at the Johns Hopkins University School of Medicine.
The finding, from a survey of more than 400 transplant surgeons, suggests that fear of legal or regulatory consequences -- rather than patient safety -- was driving changes in practice, Segev and colleagues reported in the January issue of Archives of Surgery.
In 2007, transplants from a single high-risk donor transmitted both HIV and hepatitis C to four organ recipients, despite negative antibody tests before the procedures. The case made national headlines, Segev and colleagues noted, and sparked a debate about informed consent and testing for HIV.
One of the issues was the use of the antibody test for HIV and hepatitis C, which in the first weeks after infection -- 22 days for HIV and 82 for hepatitis C -- cannot detect the presence of the viruses.
After the discovery of the transmission, physicians retrospectively used nucleic acid testing -- which reduces the discovery window to nine and seven days for HIV and hepatitis C, respectively -- and confirmed the donor had been infected.
To see what effect the case had, Segev and colleagues surveyed transplant surgeons across the U.S. between Jan. 17, 2008, and April 15, 2008, getting responses from 422 surgeons in current practice.
Of those, they found, 297 reported using high-risk donors, but 31.6% changed practice after the 2007 event. Specifically:
• 41.7% of those who changed decreased use of high-risk donors.
• 34.5% increased the emphasis on informed consent.
• 16.7% increased use of nucleic acid testing.
• 6% implemented a formal policy.
Surgeons who did not change were in practice longer, the researchers found -- 13.9 years versus 10.7, which was significant at P=0.002. They were also less likely to rank being sued or facing hospital pressure as disincentives (both differences significant at P≤0.001), but both groups saw the medical risks of HIV and hepatitis C in transplants as high (greater than four on a five-point scale).
In multivariate analyses of the reasons for changing practice, the researchers found that ranking the fear of being sued or hospital pressure as important disincentives was associated with higher odds of changing practice. The odds ratios were 2.26 and 2.52, respectively, and both were significant at P<0.05.
On the other hand, ranking the medical risks of HIV and hepatitis C in transplants as disincentives to high-risk donor use were not significant predictors of a change in practice overall, but did predict avoiding the use of high-risk donors. The odds ratios were 8.29 for HIV risk and 5.70 for hepatitis C risk, and both were significant at P<0.05.
Among physicians who changed practice, the researchers argued, most changes could be classified as "defensive medicine."
That finding is "worrisome," they noted, because high-risk donors contribute 8.6% of recovered organs and offer "significant survival benefit" despite a small risk of transmitting infectious disease.
The researchers cautioned that the data were self-reported, so it is possible that surgeons either over- or underreported changes to their practice following the 2007 event. It's also possible that those who responded to the survey differ from those who did not respond, they noted, although survey respondents represented 89.1% of U.S. transplant volume.
Finally, they cautioned that the survey took place after the 2007 case, so that recall bias is possible.
The researchers did not report external financial support for the study, nor did they report any relevant financial relationships.
Primary source: Archives of Surgery
Source reference:
Kucirka LM, et al "Provider response to a rare but highly publicized transmission of HIV through solid organ transplantation" Arch Surg 2011; 146(1): 41-45.
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