A Conceptual Model for Sources of Differential Selection in Lung Transplant Allocation.

RATIONALE: In the U.S., donor lungs are allocated to transplant candidates based on lung allocation scores (LAS). However, additional factors beyond the LAS can impact who is transplanted, including listing and donor-organ acceptance practices. These factors can result in differential selection, undermining the objectivity of lung allocation. Yet their impact on the lung transplant pathway has been under-explored.

OBJECTIVES: We sought to systematically examine sources of differential selection in lung transplantation via qualitative methods.

METHODS: We conducted semi-structured qualitative interviews with lung transplant surgeons and pulmonologists in the U.S. between June 2019 and June 2020 to understand clinicians' perspectives on differential selection in lung transplantation and the LAS.

RESULTS: 51 respondents (30 surgeons, 21 pulmonologists) identified many sources of differential selection arising throughout the pathway from referral to transplantation. We synthesized these sources into a conceptual model with five themes: 1) transplant center's level of risk tolerance and accountability, 2) successfulness/fairness of the LAS, 3) donor-organ availability and regional competition, 4) patient health versus program health, and 5) access to care versus responsible stewardship of organs.

CONCLUSIONS: Our conceptual model demonstrates how differential selection can arise throughout lung transplantation and facilitates further study of such selection. As new organ allocation models are developed, differential selection should be considered carefully to ensure that these models are more equitable.