Friday, November 24, 2017

An 8-person chain in Chicago, with news coverage

A non-directed donor chain at Northwestern, with pictures:
U.S. News Sits In as Surgeons Carry Out an 8-Person Kidney Exchange
"Four people received new leases on life via the transplant 'chain' at Chicago's Northwestern Memorial Hospital."

"Such "paired exchanges," first performed in the U.S. at Rhode Island Hospital in 2000, have taken off in the last seven years or so as a way to shorten what can otherwise be a long wait for a healthy kidney. Some 97,000 people are now on the waiting list maintained by the United Network for Organ Sharing, a nonprofit that manages the federal organ transplant system; the average wait time is generally about three to five years. That's too long for many people: About 12 die each day as they hope for a kidney to turn up. A swap like this one effectively fast-tracks the process. At Northwestern, the period between joining the exchange program and surgery typically varies from about two to six months depending on the difficulty of matching.

"Today, 20 to 30 percent of living donor kidney transplants here are done through the paired exchange program, mostly in four- to eight-person swaps. Each week, clinicians run a computer program to explore potential matches from among the incompatible pairs in the system. "There are actually multiple potential solutions that we can look through," says John Friedewald, a transplant nephrologist and medical director of the kidney transplant program. Northwestern also participates in the UNOS kidney paired donation program, which includes roughly 250 paired donors and candidates across the country. The National Kidney Registry, another nonprofit organization, facilitates hundreds of exchanges a year nationwide. In 2015, the NKR organized the longest swap to date, a 70-person chain involving teams at 26 hospitals.
"Condreva "was very hard to find a match for, so this was sort of a needle in the haystack," Friedewald says. But early this summer, when the altruistic donor approached Northwestern and was determined to be an answer for Condreva, that kidney was the first domino that allowed the other matches to be made. U.S. News visited Northwestern Memorial in late June to attend the surgeries – and the celebration days later when the donors and recipients met."

Thursday, November 23, 2017

Signaling in resident and fellowship matches to reduce interview congestion

An article by Dr. Joseph Bernstein in Clinical Orthopaedics and Related Research (December 2017, Volume 475, Issue 12, pp 2845–2849 ) argues that a signaling mechanism might help deal with congestion in the Orthopaedic Surgery match.
"Not the Last Word: Want to Match in an Orthopaedic Surgery Residency? Send a Rose to the Program Director," (gated)

I was invited to write the comment, below, which appeared along with two other (less favorable) comments from surgeons. (All of the comments appear, without titles, in the same Not the Last Word column at the link...)

Roth, Alvin E. “Congestion and signaling in residency matching,” Clinical Orthopaedics and Related Research, December 2017, 475: 2847, 2849

Now that applying to many residency programs is easy, programs receive so many applications that they have trouble deciding whom to interview, particularly because receiving an application is no longer as strong a signal of interest as it was when applying was harder [1]. The same could be said for how residents applied to colleges when they were younger, and how they will apply to fellowships when they are older. The internet and common application tools make sending applications easier, and evaluating them harder. (This is the common problem of congestion: e.g. it’s harder to use email when we get too many emails, etc.…)

In congested markets, in which not every interesting applicant can be interviewed, signals are important. An application itself is a signal about an applicant’s accomplishments. Like a peacock’s tail, it shows how desirable a candidate is, i.e. why the program should be interested in the applicant. When a program receives too many applications it becomes more costly to read them all, but each one continues to convey the applicant’s accomplishments.

What is lost when applications are easy to send is how interested the applicant is in the program. And, in a congested market, it helps to be able to signal not only how interesting you are, but also how interested, because programs that can’t interview every attractive applicant need to devote much of their interviewing to applicants who might ultimately be interested.

In Economics, the AEA’s signaling system allows each candidate to send no more than two signals of particular interest in being interviewed, for free [2].  Why [only] two? Because while it can be shown how one signal can unambiguously improve the process of selecting candidates for interviews [3], too many signals could harm the process.  Suppose we allowed 50 signals: then the absence of a signal would start to be a signal itself (“this candidate must not be interested in us at all if he didn’t even send us one of his 50 signals…”)  Signals get much of their value by being scarce. So when you can send only two, a program which receives one knows that you targeted them as one of only two recipients.

To which programs should a candidate signal? We advise candidates not to send either of their signals to the very top programs in their field. Those programs can simply interview the candidates they like best, since they have good reason to believe that every application signals genuine interest. Signals will do the most good if sent to programs that should be interested in the candidate, but to whom it might not be obvious that he or she is interested in them.

The resident match removes congestion from the process of making offers and accepting or rejecting them, since each participant can submit a long rank order list that is processed centrally [4]. But interviewing remains congested, because interviews take time. It is worthwhile considering how changes in the market design [5] could smooth the process.  Organizing a signaling system—and then monitoring how it works--seems like a promising step.

[1] Bernstein, Joseph, “Want to Match in an Orthopaedic Surgery Residency? Send a Rose to the Program Director,” this journal, this issue [?]
[2] Coles, Peter, John H. Cawley, Phillip B. Levine, Muriel Niederle, Alvin E. Roth, and John J. Siegfried, “The Job Market for New Economists: A Market Design Perspective,” Journal of Economic Perspectives, 24,4, Fall 2010, 187-206.
[3]  Coles, Peter, Alexey Kushnir and Muriel Niederle, “Preference Signaling in Matching Markets”, American Economic Journal: Microeconomics, 2013, 5(2), 99-134
[4] Roth, Alvin E.  “The origins, history, and design of the resident match,” JAMA. Journal of the American Medical Association, vol. 289, No. 7, February 19, 2003, 909-912.

[5] Roth, Alvin E. Who Gets What—and Why: The New Economics of Matchmaking and Market Design, An Eamon Dolan Book, Houghton Mifflin Harcourt, Boston, New York, 2015.

Wednesday, November 22, 2017

Kidney exchange in Mexico

Here's the story of one of the first kidney exchange transplants in Mexico, as part of a global kidney exchange chain in the U.S.
Donación renal pareada, ¿qué es y a quién beneficia? (Paired renal donation, what is it and who benefits?)

Continuing with Google translate:

"Three months later [after the tests on the patient and donor] the call arrived. Within a few days, the donor / recipient verification protocol was initiated in order to reiterate compatibility. While the process lasted for 15 days, it ensured that the process went smoothly. They were operated by Dr. Michael Rees and his team, who explained the steps that would be followed for the transplant of Rafael and the donation of Beatriz.

It was an operation of almost 11 hours. The recovery was quick, after two days Rafael was already walking and on the fourth day he was discharged. Beatriz's donation was a week later, with which she had saved two lives: Rafael's and her receiver's.

In Pro-Renal we want to continue forming life chains. If you have a relative or know someone who has kidney failure and is waiting for a kidney transplant, we share the following requirements.

How to access the Paired Renal Donation Program in Mexico?

1. To have a family member who, although incompatible with the patient, wishes and accepts to donate a kidney.

2. Once the couple enrolls in the program, different genetic tests and histocompatibility studies will be performed in order to record the information in the system.

3. The "Compatibility Algorithm" will be applied, which will determine the affinity with other recipient / donor couples.

4. When a potential match is found in the system, more advanced medical tests will be conducted to confirm the match.

5. Once the compatibility is identified, the patient can have a real live donor option, so that his medical institution can proceed with the transplant protocol.

It is important to note that all couples who are candidates for transplantation must comply with the requirements required by the Ministry of Health and the General Health Law to determine the voluntary action of the donation."

Tuesday, November 21, 2017

Surrogacy in Australia

From the blog Above the Law:
A Terrible Ruling Leaves Thousands Of Children Without Legal Parents
Even the judge acknowledged that his ruling was deeply problematic.

" The Bernieres ... were an Australian couple who couldn’t conceive the old-fashioned way. Unable to have a child without help, they journeyed from their home in Melbourne to a fertility clinic in India. The hopeful parents-to-be were advised that their best chances to conceive were to use an anonymous egg donor, and a gestational carrier. The couple entered into the arrangement in 2013, and in 2014 their child was born. They brought a baby girl back to Australia. But they made the mistake of asking a Victorian court to bless the arrangement, and declare them legal parents of their own child. The court did not feel so inclined.
Justice Berman, the trial judge, agreed to let the child remain in the Bernieres’s care; however, he determined that they could not be found to be parents of the child because they did not meet the terms of the Victorian surrogacy statute, Section 60HB of the Family Law Act. The narrow statute requires that (1) surrogacy only be undertaken through a Victorian registered ART provider, (2) the procedure must be carried out in Victoria, and (3) the arrangement can only be altruistic (the surrogate cannot be paid). Further, the judge determined that without specific authority to find the Bernieres as parents to the child, his hands were tied.
Despite the fact the Mr. Bernieres was both the biological and intended parent of the child, Justice Berman determined that Mr. Bernieres could not be declared a parent to the child. But unfortunately, that judgment meant that literally no one was a legal parent of the child.
Justice Berman acknowledged that his ruling was deeply problematic for the child at issue, and noted the need for “urgent legislative change.” Two years later — and with no legislative change in sight — the case went up on appeal before the full panel of the Australian Family Court. In September 2017, the Family Court made its ruling. The Court affirmed the judgment that the judiciary had no authority to declare the Bernieres as the legal parents of the child. Here’s the order. It’s a megabummer.
Thousands Of Children Affected. The broader tragedy is that the Bernieries did not represent an isolated case. Experts estimate that 250 Australian families conceive through surrogacy arrangements abroad each year. So the implication of this ruling is that there are thousands of children in Australia with no legal parents."

Monday, November 20, 2017

Who Gets What and Why in Vietnamese: Sách Ai được gì và tại sao

Who Gets What and Why has come out in Vietnamese:
Nobel Kinh tế Giáo sư Alvin Roth – Sách Ai được gì và tại sao (Who gets what and why)

The book comes with a foreword I wrote for the Vietnamese edition, after corresponding about it with Quoc-Anh Do.  The foreword touches on translation, so it's interesting to note that Google translate at the above link doesn't yet do so well. Here is the original (instead of the automatic back translation into English of the human translation into Vietnamese by Dang Tùng.)

Foreword to the Vietnamese Edition

The translation of a book about markets from English to Vietnamese is an opportunity to remember that markets, like languages, are ancient human artifacts. Markets and languages are both tools that human beings construct together to help us coordinate with one another, and that we constantly update to meet modern needs.

Just as there are different languages, there are different kinds of markets, and different ways to organize them. Commodity markets are markets in which prices determine who gets what, and market participants can deal with one another anonymously. But many markets involve relationships, and in those markets you care who you are dealing with, and who gets what isn’t decided by prices alone.  Matching markets are markets in which you can’t just choose what you want, but also must be chosen.  Prices don’t do all the work in matching markets, and sometimes we don’t let prices play any role at all. Matching in one form or another determines who goes to which schools and universities, who gets which jobs, and who marries whom, and sometimes who gets certain kinds of medical care, like organ transplants.

Most markets and marketplaces operate in the substantial space between Adam Smith’s invisible hand and Chairman Mao’s five-year plans. Markets differ from central planning because no one but the participants themselves determines who gets what. And marketplaces differ from anything-goes laissez faire because participants enter the marketplace knowing that it has rules.

Market design is about finding rules to make markets work well. Often this is a process of trial and error. For example, in many countries, the process of school assignment and university admissions is riskier and more stressful for students than it needs to be. This book describes how my colleagues and I have helped make school choice safer and simpler for many American students, and made it likely that they will get schools that they prefer. Perhaps our experience can help Vietnamese economists and policy makers get some ideas about how to improve the famously stressful college admissions process in Vietnam.  

The book also describes how the system of matching doctors to their first jobs was redesigned in the United States and elsewhere, and some of the problems that had to be overcome in those markets, and similar ones.

I hope this book will help readers look at who gets what and how in Vietnam, and find ways to make some of those markets work better.
Alvin E. Roth
Stanford, California

12 January 2017

Sunday, November 19, 2017

Big Dialysis (or, why we need to increase access to transplants)

Here's a polemical story from the Washington Monthly: it gives a good picture of why it's pretty terrible to be on dialysis, but casts blame too quickly on the big dialysis companies (while downplaying the complex roles of Medicare and organ shortages...)
The Dialysis Machine
How Medicare steers low-income and minority kidney patients toward the hell of dialysis—and keeps two big companies rolling in profits.

Saturday, November 18, 2017

The Trump administration considers, and reconsiders, another approach to saving elephants

Here's a story about a policy the Trump administration announced and then paused on:

The Washington Post has the first story here
Trophies from elephant hunts in Zimbabwe were banned in the U.S. Trump just reversed that.  By Juliet Eilperin and Darryl Fears November 16

"The Trump administration is now allowing the remains of elephants legally hunted in Zimbabwe and Zambia to be imported to the United States as trophies, with officials signaling they will expand efforts to promote trophy hunting as a form of conservation.
African elephants are listed as threatened under the Endangered Species Act, but the U.S. Fish and Wildlife Service has determined that large sums paid for permits to hunt the animals could actually help them “by putting much-needed revenue back into conservation,” according to an agency statement late Wednesday.
Under the Obama administration, elephant-hunting trophies were allowed in South Africa and Namibia but not in Zimbabwe because Fish and Wildlife decided in 2015 that the nation had failed to prove that its management of elephants enhanced the population. At the time, Zimbabwe could not confirm its elephant population in a way that was acceptable to U.S. officials and did not demonstrate an ability to implement laws to protect it.
"The change applies to elephants shot in Zimbabwe on or after Jan. 21, 2016, and to those legally permitted to be hunted before the end of next year.
The African elephant population in that country has fallen 6 percent in recent years, according to the Great Elephant Census project. It is relatively stable in Zambia, which has decided to renew hunting after having previously banned it because of several decades of sharp decline.
"The shift in U.S. policy comes just days after Interior Secretary Ryan Zinke established an “International Wildlife Conservation Council” to advise him on how to increase Americans’ public awareness of conservation, wildlife enforcement and the “economic benefits that result from U.S. citizens traveling abroad to hunt.”

And here's the second installment:
Trump halts big-game trophy decision By Ashley Parker November 17
"President Trump abruptly reversed his administration’s Thursday decision to allow elephants shot for sport in Zimbabwe and Zambia to be imported back to the United States as trophies, saying in a tweet Friday night that he was putting the decision “on hold” until further review.
"Trump’s sudden tweet halted a decision by his own administration, announced by the U.S. Fish and Wildlife Service on Thursday, to end a 2014 government ban on big-game trophy hunting in Zimbabwe and Zambia, saying it would help the conservation of the species."