Modeling Kidney Transplantation Decisions: Regulatory Oversight, Information Sharing, and Post-Transplant Drug Choice

The United States and many other nations are encountering a disturbing obstacle: A shortage of available organs for patients who are in need of kidney transplantation. This dissertation strives to analyze this trend and present potential solution by focusing on three different aspects, namely regulatory oversight, information sharing, and post-transplant immunosuppressant drug choice. In my first essay, I propose a stochastic model that identifies a socially-optimal kidney transplant choice given the inherent trade-off between the expected wait time (driven by supply and demand) and the quality of received donor kidney. I modify the model to account for changes made by the introduction of performance assessment in 2007 and the new kidney allocation system in 2014. Empirical analysis indicates that the current risk-adjusted post-transplant performance assessment policy might be more effective if regulators also adjust the model based on the differences in organ availability by regions and candidate\u27s blood type. Motivated by the high kidney discard rate in the US, in my second essay I develop a simulation model that considers the effect of several important factors that affect kidney utilization. Unlike most proposed models, the presented simulation reflects details of the offering process, the deterioration of patient health and kidney quality over time, the correlation between patient\u27s health and acceptance decision, and the probability of kidney acceptance. I apply the model to perform two different analyses. The former considers an individual-level strategy one may choose to contribute to the improvement of kidney discard rate, opting for simultaneously enlisting in multiple regions. one can be waitlisted given her individualized set of constraints. The latter focuses on a macro-level aspect of transplantation, namely the contribution of information sharing on the social welfare and discard rates. Long-term successful post-transplant outcome necessitates the use of immunosuppressant drug therapy to prevent immunologic rejection and maintain transplanted kidney function. Since kidney transplantation is primarily financed through public funds in the U.S. (Medicare), in my third essay I define, from the payer\u27s perspective, the incremental cost-effectiveness among four different treatment regimens, i.e., no-induction, IL2-RA, r-ATG, and alemtuzumab. The analysis indicates that antibody-based induction appears to offer substantial advantages regarding both cost and outcome compared to no-induction. Overall, depletional induction (preferably r-ATG) provides the highest benefit. Organ transplantation is a complicated process which is continuously changing. This thesis cannot cover all aspects but provides valuable insights into several important issues