Ensuring equity in vascularized composite allotransplantation

By Laura L. Kimberly, Elie P. Ramly, and Eduardo D. Rodriguez

Vascularized composite allotransplantation (VCA) can be considered the innovative cousin of solid organ transplantation. VCA is the transplantation of multiple tissues, such as skin, muscle, nerve, and bone as a functional unit. This includes facial, upper and lower extremity, uterine, penile and abdominal wall transplantation. While these procedures are similar to solid organ transplants in some ways, they differ notably in that the primary impact of VCA is on quality of life, whereas solid organ transplantation is typically considered lifesaving.

Some forms of VCA, including hand and face transplantation, are beginning to transition from experimental research to innovative therapy, and future sustainability of the field will depend in part on whether health insurers are willing to offer coverage for VCA procedures, as research funding concludes.

With the field at an inflection point of sorts, there is an opportunity to proactively incorporate a focus on equity in the quest for financial sustainability. Moreover, it is time for the field to begin interrogating other forms of inequity beyond cost that may impede fair access to VCA.

In solid organ transplantation, disparities in access based on race and ethnicity, age and gender have been well-documented in the published literature. Barriers to access are present at multiple touch points along the transplant continuum, from likelihood of referral for initial evaluation, to acceptance as a candidate and placement on the waiting list, to eventual transplantation. Particularly with respect to racial and ethnic disparities, the field of solid organ transplantation has grappled with implementing effective strategies to support health equity.

Over the past six months, convergence of the COVID-19 pandemic and the global push for racial justice has underscored an ethical imperative to confront health care disparities that cannot be ignored. In solid organ transplantation, some positive signs of progress are underway, including a new Inclusion, Diversity, Equity, and Access to Life (IDEAL) task force to combat systemic racism, convened by the American Society of Transplantation. As VCA procedures evolve toward standard of care, the field should maximize every opportunity to build equity into its foundation. VCA can and should heed this call to action to address disparities and promote health equity.

 

Paper title: Equity in Access to Facial Transplantation

Authors: Laura L. Kimberly1,2, Elie P. Ramly1, Allyson R. Alfonso1, Gustave K. Diep1, Zoe P. Berman1, Eduardo D. Rodriguez1

Affiliations:

1Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY 10017, United States

2Division of Medical Ethics, Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, United States

Competing interests: None

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