Potential for deceased donation not optimally exploited: donor action data from six countries.

BACKGROUND: Most countries today promote living donation as an alternative to challenge the organ shortage from deceased donors. This seems justifiable provided the potential for deceased donation is optimally exploited. METHODS: We used the Donor Action (DA) Medical Record Review (MRR) methodology in six countries, to measure whether the potential for heart-beating (HB) deceased donors was adequately converted to donation. Medical record review data were collected from 52,383 patients who died in 605 critical care units in 227 hospitals between January 2007 and December 2009. RESULTS: On a total of 17,903 ventilated patients aged younger than 76 years and without contraindications to HB donation, 4,855 cases met criteria for brain death (BD) diagnosis and were considered potential HB donors. On average, 24.8±15.9% was not identified as potential donor, 21.9% of identified cases was not referred as such to a procurement team, and in 11.3% of identified cases, no approached was offered with the option to donate. Average consent rates/family approaches or registry consultation was 69.1±14.5%, and average conversion of potential into actual donors was 42.1±7.3%. CONCLUSIONS: Over 57% of deceased potential donors in the study cohort were missed along the donation pathway because of nonidentification, no referral, no approach of relatives, or objections to donate. In countries with lower donation rates, expectedly more potential donors are missed proportionally. Efforts to increase the organ pool should therefore focus on optimizing clinical practices in deceased organ donation in addition to promoting living organ donation.

Worldwide variability in deceased organ donation registries.

The variability in deceased organ donation registries worldwide has received little attention. We considered all operating registries, where individual wishes about organ donation were recorded in a computerized database. We included registries which recorded an individual's decision to be a donor (donor registry), and registries which only recorded an individual's objection (non-donor registry). We collected information on 15 characteristics including history, design, use and number of registrants for 27 registries (68%). Most registries are nationally operated and government-owned. Registrations in five nations expire and require renewal. Some registries provide the option to make specific organ selections in the donation decision. Just over half of donor registries provide legally binding authorization to donation. In all national donor registries, except one, the proportion of adults (15+) registered is modest (<40%). These proportions can be even lower when only affirmative decisions are considered. One nation provides priority status on the transplant waiting list as an incentive to affirmative registration, while another nation makes registering a donation decision mandatory to obtain a driver's license. Registered objections in non-donor registries are rare (<0.5%). The variation in organ donor registries worldwide necessitates public discourse and quality improvement initiatives, to identify and support leading practices in registry use.

The European experience.

This mini-review on European experiences with tackling the problem of organ shortage for transplantation was based on a literature review of predominantly European publications dealing with the issue of organ donation from deceased donors. The authors tried to identify the most significant factors that have demonstrated to impact on donation rates from deceased donors and subsequent transplant successes. These factors include legislative measures (national laws and European Directives), optimization of the donation process, use of expanded criteria donors, innovative preservation and surgical techniques, organizational efforts, and improved allocation algorithms.

Critical Care staffs' attitudes, confidence levels and educational needs correlate with countries' donation rates: data from the Donor Action database.

To investigate on the impact of Critical Care (CC) staffs' attitudes to donation, their acceptance of the brain death (BD) concept, their confidence with donation-related tasks and educational needs on national donation rates. Donor Action (DA) Hospital Attitude Survey (HAS) data were collected from 19 537 CC staff in 11 countries, including personal attitudes to donation, self-reported knowledge, involvement and comfort levels with donation-related tasks and educational requirements. Countries' donation performance was expressed as Procurement Efficiency Index (PEI) (organs procured and transplanted/deaths from eligible causes). National PEI rates correlated well with CC staffs' average support to donation (R = 0.700, P = 0.014), acceptance of the BD concept (R = 0.742, P = 0.007), confidence levels (R = 0.796, P = 0.002) and average educational requirements with donation-related tasks (R = -0.661, P = 0.025). Nurses reported significantly lower positive attitudes (P < 0.0001), acceptance of the BD concept (P < 0.0001), comfort levels (P < 0.0001) and requested more education (P = 0.0025) than medical staff members. DA's HAS is a powerful, standardized tool to assess CC staffs' attitudes and donation-related skills in different environments. Measures to improve countries' donation performance should focus on guidance and education of CC staff so as to ensure that all practitioners have sufficient knowledge and feel comfortable with donation-related issues.

Donation after uncontrolled cardiac death (uDCD): a review of the debate from a European perspective.

Presumed consent alone will not solve the organ shortage, but it will create an ethical and legal context that supports organ donation, respects individuals who object to organ donation, relieves families from the burden of decision making, and can save lives.

Donation patterns in four European countries: data from the donor action database.

BACKGROUND: To analyze heart-beating organ donation patterns in four countries using the Donor Action (DA) Program nationally and to identify areas for improvement. METHODS: Medical Record Review (MRR) of 18,118 critical care deaths between January 2006 and December 2007 in Belgium, Finland, France, and Switzerland. Data were entered to the DA System Database for analysis. RESULTS: Of 6561 patients without contraindications to donation, 45.3% met preconditions for brain death (BD) diagnosis, 31.4% had signs of severe brain damage and 28.8% met criteria for formal BD diagnosis. Belgium had the highest number of patients with formal BD diagnosis (75.7%) and Switzerland (57.4%, P<0.0001) the lowest. Although donor identification rates were uppermost in France (93.6%) and lowest in Finland (47.7%, P<0.0001); Finland excelled in donor referral (93.9% of identified cases) versus only 63.8% in Switzerland (P<0.0001), and excelled in family approach rates (92.7%) versus only 70.2% in France (P<0.0001). Consent rates were superior in Belgium and Finland and lowest in France (P<0.0001). Conversion rates (percent of potential donors vs. actual donors) were higher in France and Belgium and significantly lower in Finland and Switzerland (P=0.0187). Only Belgium had a non-heart-beating donation policy during the study period, resulting in 11.2% more donors added to the country's donor pool. CONCLUSIONS: The DA MRR proved to be an excellent tool to identify areas of improvement within certain steps of the donation process. Moreover, DA's MRR has shown to be applicable in different countries and environments and should be considered as a unique tool for comparing countries' donation performance.

An analysis of critical care staff's attitudes to donation in a country with presumed-consent legislation.

CONTEXT: Lack of knowledge and confidence among critical care staff in identifying potential donors and communicating with donor families may explain missed organ and tissue donations. OBJECTIVES: To elucidate attitudes of critical care staff toward donation and their knowledge, involvement, and self-reported skills and confidence levels with donation-related tasks. METHODS: Between January 2004 and May 2006, Donor Action Foundation's Hospital Attitude Survey was used to collect data from staff members in critical care units in our university hospital (study group) and 2 other Belgian university hospitals (control group). In total, 92 physicians, 433 nurses, and 26 other staff members participated. RESULTS: The 2 groups did not differ significantly with regard to donation-related attitudes. The study group had a significantly lower perception of the public's approval of organ donation than did the control group (P < .001). Nurses reported significantly less involvement than did physicians (P < .001) in caring for potential donors, communicating severe brain damage, explaining brain death, requesting donation, and contacting procurement staff. Probably because of previous training, physicians in the study group reported less need for additional training on donation-related issues than did control physicians. However, compared with physicians, nurses in the study group requested significantly more training on a number of donation tasks. Nurses with more than 5 years of critical care experience were consistently more confident with donation-related tasks. CONCLUSION: Support rates for donation are high overall, and previous training is associated with improved attitudes and decreased educational needs. Educational efforts tailor-made for nurses should increase nurses' confidence levels when confronted with potential donors and their next of kin.

Waiting for a thoracic transplant in Eurotransplant.

The prospects of patients on the thoracic waiting list are governed by the chance of receiving an organ in time and by the outcome of the transplantation. The former probability is determined by a triad of disease severity, resource size and allocation rules. The aim of this study was to provide an objective description of the distributional effects of the thoracic allocation system in Eurotransplant. It appears that the interpretation of waiting-list outflow indicators is not straightforward and that it is difficult to assess the fairness of an organ allocation system in the framework of changing donor-organ availability. The timing of listing for heart transplantation can substantially be improved; whether this is also true for lung transplantation cannot be determined from the available data. Allocation schemes cannot solve the problem of organ shortage; a shift of attention toward collaboration with procurement professionals is needed.

Cost-effectiveness of organ donation: evaluating investment into donor action and other donor initiatives.

Initiatives aimed at increasing organ donation can be considered health care interventions, and will compete with other health care interventions for limited resources. We have developed a model capable of calculating the cost-utility of organ donor initiatives and applied it to Donor Action, a successful international program designed to optimize donor practices. The perspective of the payer in the Canadian health care system was chosen. A Markov model was developed to estimate the net present value incremental lifetime direct medical costs and quality adjusted life years (QALYs) as a consequence of increased kidney transplantation rates. Cost-saving and cost-effectiveness thresholds were calculated. The effects of changing the success rate and time frame of the intervention was examined as a sensitivity analysis. Transplantation results in a gain of 1.99 QALYs and a cost savings of Can$104,000 over the 20-year time frame compared with waiting on dialysis. Implementation of an intervention such as Donor Action, which produced as few as three extra donors per million population, would be cost-effective at a cost of Can$1.0 million per million population. The cost-effectiveness of Donor Action and other organ donor initiatives compare favorably to other health care interventions. Organ donation may be underfunded in North America.

Cost-benefit approach in evaluating investment into donor action: the German case.

Donor Action (DA) is an international initiative to help critical care units (CCUs) increase their own donation rates through improved-quality donation practices. Following a validated diagnostic review (DR), areas of weakness can be identified, and the appropriate changes introduced. Data gathered from a number of centers in nine European countries (including Germany) 1 year after the introduction of targeted improvement measures demonstrated a 59.2% (P=0.0015) increase in donation rates. This analysis computes the cost-benefit thresholds of implementing the DA methodology from a German health-economic point of view, taking into account the treatment alternatives for end-stage renal disease (dialysis and transplantation) and comparing the DA program with current organ-donation practice. Lifetime direct medical costs and quality-adjusted life years (QALYs) were calculated for both arms, considering only changes in cadaveric renal transplantation rates. If DA leads to a 59% overall increase in organ donation in Germany, the program will result in 33 QALYs and 1.8-million euro cost savings per million population (PMP). Therefore, DA would be cost-effective below 2.66-million euro implementation cost PMP (or 218-million euro for the whole country). As the partial implementation cost of the program was far below the threshold, DA is more cost-effective than other publicly reimbursed medical intervention.

How to improve organ donation: results of the ISHLT/FACT poll.

BACKGROUND: Worldwide organ shortages remain a long-standing problem. Efforts to address this have ranged from attempts to improve public awareness to modified mandated choice systems; most have been unsuccessful. In the face of this intractable problem, increased consideration has been given to direct and indirect compensation, and in certain countries, black markets for organs have developed. To examine the attitudes of the transplant medical community regarding these issues, we surveyed members of the International Society for Heart and Lung Transplantation (ISHLT) in conjunction with the Foundation for the Advancement of Cardiac Therapies (FACT). METHODS/RESULTS: We asked for opinions about how to improve organ donation. Of 739 respondents, 75% supported presumed consent, and 39% identified it as the single best way to increase donation; improved public education was a distant second (18%). Seventy percent supported indirect compensation (e.g., payment of funeral expenses, donation to a charity of the family's choice), and 66% opposed direct compensation (e.g., tax credit, life insurance benefit). When asked whether next of kin should be consulted regarding organ donation, and 84.2% responded affirmatively. However, of these individuals, 77.2% did not think that consultation should be required if the potential donor already had signed a donor card. MEMBERSHIP: Our membership dramatically favors indirect over direct compensation as a way of increasing organ donation. The majority also favors the wishes of the individual over the family in determining donor status. However, presumed consent is the single best way to significantly improve organ donation, according to the majority of our respondents. More effort should be directed toward policy in these areas as opposed to improving public education, which has failed to yield satisfactory results.

Joining efforts in tackling the organ shortage: the Donor Action experience.

1. Donor Action takes a systematic approach towards achieving quality assurance in the whole donation process. It is designed to give hospitals participation and ownership of donation practices that can be tailored to meet identified needs in critical care units (CCUs). The program has been successfully introduced in 18 countries and in over 250 CCUs in North and South America, Europe and Asia. 2. Aggregated data collected in 162 CCUs in 10 countries showed significant losses of potential donors along the donation pathway. The major factor impacting on converting medically suitable cases with signs of brain death into potential donors was the willingness of CCU staff to formally diagnose brain death. Major reasons for non-donation in BD-diagnosed cases were non-referral (26.5%), family refusal (20%), or no approach of next-of-kin (13.2%). 3. Pre-intervention data show that professional training, clear role definitions, teamwork, comprehensive guidelines and consistent protocols dealing with all donation-related tasks in the CCU setting are critical to achieve optimal donation rates. 4. Implementation of these improvement measures in 10 countries have shown an immediate overall increase of donation rates of 59% after 1 year and a sustained, even growing effect on referral and donation rates in those countries with sufficient follow-up, proving a permanent impact of DA's methodology. 5. As a health-economic evaluation, based on the German case, shows that the implementation cost of the program in pilot centers was far below the investment thresholds. Donor Action is more cost-effective than other publicly reimbursed medical interventions. Incorporating health economic consequences of other cadaveric organ transplants into the analysis could even further improve the cost-benefit ratio of Donor Action compared with current organ donation practices.