Factors influencing deceased organ donation rates in OECD countries: a panel data analysis.

OBJECTIVES: This study aims to investigate factors with a significant influence on deceased organ donation rates in Organisation for Economic Co-operation and Development (OECD) countries and determine their relative importance. It seeks to provide the necessary data to facilitate the development of more efficient strategies for improving deceased organ donation rates. DESIGN: Retrospective study. SETTING: Publicly available secondary annual data. PARTICIPANTS: The study includes 36 OECD countries as panel members for data analysis. OUTCOME MEASURES: Multivariable panel data regression analysis was employed, encompassing data from 2010 to 2018 for all investigated variables in the included countries. RESULTS: The following variables had a significant influence on deceased organ donation rates: 'opt-in' system (ß=-4.734, p<0.001, ref: 'opt-out' system), only donation after brain death (DBD) donors allowed (ß=-4.049, p=0.002, ref: both DBD and donation after circulatory death (DCD) donors allowed), number of hospital beds per million population (pmp) (ß=0.002, p<0.001), total healthcare employment pmp (ß=-0.00012, p=0.012), World Giving Index (ß=0.124, p=0.008), total tax revenue as a percentage of gross domestic product (ß=0.312, p=0.009) and percentage of population aged ≥65 years (ß=0.801, p<0.001) as well as high education population in percentage (ß=0.118, p=0.017). CONCLUSIONS: Compared with the promotion of socioeconomic factors with a positive significant impact on deceased organ donation rates, the following policies have been shown to significantly increase rates of deceased organ donation, which could be further actively promoted: the adoption of an 'opt-out' system with presumed consent for deceased organ donation and the legal authorisation of both DBD and DCD for transplantation.

A multi-national, video-based qualitative study to refine training guidelines for assigning an "unsafe" score in laparoscopic cholecystectomy critical view of safety.

BACKGROUND: The critical view of safety (CVS) was incorporated into a novel 6-item objective procedure-specific assessment for laparoscopic cholecystectomy (LC-CVS OPSA) to enhance focus on safe completion of surgical tasks and advance the American Board of Surgery's entrustable professional activities (EPAs) initiative. To enhance instrument development, a feasibility study was performed to elucidate expert surgeon perspectives regarding "safe" vs. "unsafe" practice. METHODS: A multi-national consortium of 11 expert LC surgeons were asked to apply the LC-CVS OPSA to ten LC videos of varying surgical difficulty using a "safe" vs. "unsafe" scale. Raters were asked to provide written rationale for all "unsafe" ratings and invited to provide additional feedback regarding instrument clarity. A qualitative analysis was performed on written responses to extract major themes. RESULTS: Of the 660 ratings, 238 were scored as "unsafe" with substantial variation in distribution across tasks and raters. Analysis of the comments revealed three major categories of "unsafe" ratings: (a) inability to achieve the critical view of safety (intended outcome), (b) safe task completion but less than optimal surgical technique, and (c) safe task completion but risk for potential future complication. Analysis of reviewer comments also identified the potential for safe surgical practice even when CVS was not achieved, either due to unusual anatomy or severe pathology preventing safe visualization. Based upon findings, modifications to the instructions to raters for the LC-CVS OPSA were incorporated to enhance instrument reliability. CONCLUSIONS: A safety-based LC-CVS OPSA has the potential to significantly improve surgical training by incorporating CVS formally into learner assessment. This study documents the perspectives of expert biliary tract surgeons regarding clear identification and documentation of unsafe surgical practice for LC-CVS and enables the development of training materials to improve instrument reliability. Learnings from the study have been incorporated into rater instructions to enhance instrument reliability.

Laparoscopic cholecystectomy critical view of safety (LC-CVS): a multi-national validation study of an objective, procedure-specific assessment using video-based assessment (VBA).

BACKGROUND: A novel 6-item objective, procedure-specific assessment for laparoscopic cholecystectomy incorporating the critical view of safety (LC-CVS OPSA) was developed to support trainee formative and summative assessments. The LC-CVS OPSA included two retraction items (fundus and infundibulum retraction) and four CVS items (hepatocystic triangle visualization, gallbladder-liver separation, cystic artery identification, and cystic duct identification). The scoring rubric for retraction consisted of poor (frequently outside of defined range), adequate (minimally outside of defined range) and excellent (consistently inside defined range) and for CVS items were "poor-unsafe", "adequate-safe", or "excellent-safe". METHODS: A multi-national consortium of 12 expert LC surgeons applied the OPSA-LC CVS to 35 unique LC videos and one duplicate video. Primary outcome measure was inter-rater reliability as measured by Gwet's AC2, a weighted measure that adjusts for scales with high probability of random agreement. Analysis of the inter-rater reliability was conducted on a collapsed dichotomous scoring rubric of "poor-unsafe" vs. "adequate/excellent-safe". RESULTS: Inter-rater reliability was high for all six items ranging from 0.76 (hepatocystic triangle visualization) to 0.86 (cystic duct identification). Intra-rater reliability for the single duplicate video was substantially higher across the six items ranging from 0.91 to 1.00. CONCLUSIONS: The novel 6-item OPSA LC CVS demonstrated high inter-rater reliability when tested with a multi-national consortium of LC expert surgeons. This brief instrument focused on safe surgical practice was designed to support the implementation of entrustable professional activities into busy surgical training programs. Instrument use coupled with video-based assessments creates novel datasets with the potential for artificial intelligence development including computer vision to drive assessment automation.

Learning surgical knot tying and suturing technique - effects of different forms of training in a controlled randomized trial with dental students.

Objective: The acquisition of surgical skills requires motor learning. A special form of this is intermanual transfer by transferring motor skills from the nondominant hand (NDH) to the dominant hand (DH). The purpose of this study was to determine the learning gains that can be achieved for the DH by training with the DH, the NDH, and by non-surgical alternative training (AT). Methods: 124 preclinical (n=62) and clinical (n=62) dental students completed surgical knot tying and suturing technique training with the DH, with the NDH, and an AT in a controlled randomized trial. Results: A statistically significant learning gain in knot tying and suture technique with the DH was evident only after training with the DH when compared to training with the NDH (p<0.001 and p=0.004, respectively) and an AT (p=0.001 and p=0.010, respectively). Of those students who achieved a learning gain ≥4 OSATS points, 46.4% (n=32) benefited in their knot tying technique with the DH from training with the DH, 29.0% (n=20) from training with the NDH, and 24.6% (n=17) from an AT while 45.7% (n=32) benefited in their suturing technique with the DH from training with the DH, 31.4% (n=22) from training with the NDH, and 22, 9% (n=16) from an AT. Conclusions: Training with the DH enabled significantly better learning gains in the surgical knot tying and suturing techniques with the DH.

Systematic review on the involvement and engagement of patients as advisers for the organisation of organ transplantation services.

OBJECTIVES: This systematic review aims to derive practical lessons from publications on patient involvement and engagement in the organisation of organ transplantation services. DESIGN: This systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses. Inclusion criteria for the analysis of publications in English cited in the databases PubMed and Web of Science until 6 December 2022 required that patients participated as advisers in the organisation of organ transplantation services. Quality assessment was performed using the Guidance for Reporting Involvement of Patients and the Public (GRIPP) 2 small form and the Critical Appraisal Skills Programme (CASP) tool for the assessment of the risks of bias. RESULTS: Deployed search strings identified 2263 records resulting in a total of 11 articles. The aims and strategies, deployed methods, observed effects, observed barriers and proposed improvements for the future varied vastly. All reported that well-developed programmes involving and engaging patients at an organisational level provide additional benefits for patients and foster patient-centred care. Lessons learnt include: (1) to empower patients, the information provided to them should be individualised to prioritise their needs; (2) financial as well as organisational resources are important to successfully implement patient involvement and engagement; (3) systematic feedback from patients in organisational structures to health providers is required to improve clinical workflows and (4) the consideration of ethical issues and the relationship between investigators and participating patients should be clarified and reported. CONCLUSIONS: Actionable management recommendations could be derived. The quantitative impact on clinical outcome and economic clinical process improvements remains to be investigated. Study quality can be improved using the GRIPP 2 guidance and the CASP tool. PROSPERO REGISTRATION NUMBER: CRD42022186467.

Transplanting a left or right donor kidney into the left or right iliac fossa: importance of laterality and site of venous anastomosis.

Data on the impact of donor-to-recipient laterality on kidney transplantation are lacking. This study evaluated the impact of donor-to-iliac fossa laterality and the site of venous anastomosis on operating time and surgical outcome. This retrospective single-center study analyzed 1262 deceased donor adult kidney transplants into pristine iliac fossa. Multivariable linear and logistic regression analyses were used to identify variables with an impact on operating time and surgical complications. Operating time was shorter by 11 min in median for transplantations into the right iliac fossa compared to the left iliac fossa (p < 0.001). Operating time in left-to-right donor-to-recipient combination was shorter by 17 min in median if venous anastomoses were performed on the caval vein or common iliac vein as compared to anastomoses to the external iliac vein (p < 0.001). Overall, the shortest operating times (median 112.5 min) were achieved in left-to-right donor-to-recipient combinations with venous anastomosis to the caval or common iliac vein, without an increase in surgical complications. Kidney transplantation into the right iliac fossa with anastomosis to the caval vein or the common iliac vein saves operating time and reduces thrombotic complications. Acceptance of a left donor kidney is likely to further reduce operating time.

Preoperative hemoglobin levels, extended resections and the body mass index influence survival after pancreaticoduodenectomy.

PURPOSE: The negative influence of perioperative transfusion of packed red blood cells on the prognosis of various malignancies is the focus of recent research interest. The development of a propensity score for the prediction of perioperative transfusion of packed red blood cells (pRBCs) and the identification of independent risk factors for survival, that can either be known prior to or during surgery in patients undergoing pancreaticoduodenectomy for pancreatic head cancer are the two objectives of this study. METHODS: Logistic regression analyses and Cox regression modeling were used to identify independent risk factors for perioperative transfusion of pRBCs and to determine individual risk factors for patient survival. A total of 101 adult patients who underwent surgery between 01/01/2016 and 12/31/2020 were investigated in a single-center retrospective analysis. RESULTS: Preoperative hemoglobin levels (OR: 0.472, 95%-CI: 0.312-0.663, p < 0.001) and extended resections (OR: 4.720, 95%-CI: 1.819-13.296, p = 0.001) were identified as independent risk factors for perioperative transfusion of pRBCs, enabling the prediction of pRBC transfusion with high sensitivity and specificity (AUROC: 0.790). The logit of the derived propensity model for the transfusion of pRBCs (HR: 9.231, 95%CI: 3.083-28.118, p < 0.001) and preoperative Body Mass Index (BMI) (HR, 0.925; 95%-CI: 0.870-0.981, p = 0.008) were independent risk factors for survival. CONCLUSIONS: Low preoperative hemoglobin levels, low BMI values, and extended resections are significant risk factors for survival that can be known and thus potentially be influenced prior to or during surgery. Patient blood management programs and prehabilitation programs should strive to increase preoperative hemoglobin levels and improve preoperative malnutrition.

Setting Organ Allocation Priorities: A Discrete Choice Experiment with German Patients and Their Relatives.

Purpose: Organ transplantation systems benefit from guidelines that are harmonious with the preferences of the people involved. Discrete choice experiments are useful tools for eliciting preferences. Patients and Methods: This study evaluated the preferences of patients and their relatives (n=285) to identify their priorities in organ allocation using a discrete choice experiment. In eight hypothetical allocation decisions, the participants were asked to select the candidate they considered the most suitable The candidates differed in years of life gained after transplantation, quality of life after transplantation, waiting time until transplantation, age, compliance and social support. Results: The most important aspects for setting priority in organ allocation were lack of compliance (ß= -2.5, p<0.001) and good quality of life after transplantation (ß = +1.4, p<0.001). The lack of social support (ß = -0.8, p<0.05) and the more years of life gained after transplantation (ß = +0.5, p<0.001) had less but still a significant amount of influence on this decision, while the waiting list was not considered significantly important (ß = 0.1, p>0.05). The comparison of the different relations to transplantation showed that life years gained after transplantation was of high relevance to posttransplant patients (+10 years: ß = +0.709, p<0.001 / +15 years: ß = +0.700, p<0.001) and of no importance to waitlisted patients (+10 years: ß = +0.345, p>0.05 / + 15 years: ß = +0.173, p>0.05) and relatives (+ 10 years: ß = +0.063, p>0.05 / +15 years: ß = +0.304, p>0.05). Conclusion: This study provides useful insights into the unique perspective of patients and their relatives on priority-setting in the allocation of donor organs that should be reflected in improved donor organ allocation rules.

Proposal of a Multivariable Prediction Model for Graded Morbidity after Liver Resection for Colorectal Metastases.

BACKGROUND: Prognostic models to predict individual early postoperative morbidity after liver resection for colorectal liver metastases (CLM) are not available but could enable optimized preoperative patient selection and postoperative surveillance for patients at greater risk of complications. The aim of this study was to establish a prognostic model for the prediction of morbidity after liver resection graded according to Dindo. METHODS: N = 679 cases of primary liver resection for CLM were retrospectively analyzed using univariable and multivariable ordinal regression analyses. Receiver operating characteristics curve (ROC) analysis was utilised to assess the sensitivity and specificity of predictions and their potential usefulness as prognostic models. Internal validation of the score was performed using data derived from 129 patients. RESULTS: The final multivariable regression model revealed lower preoperative levels, a greater number of units of intraoperatively transfused packed red blood cells (pRBCs), longer duration of surgery, and larger metastases to independently influence postoperatively graded morbidity. ROC curve analysis demonstrated that the multivariable regression model is able to predict each individual grade of postoperative morbidity with high sensitivity and specificity. The areas under the receiver operating curves (AUROC) for all of these predictions of individual grades of morbidity were > 0.700, indicating potential usefulness as a predictive model. Moreover, a consistent concordance in Grades I, II, IV, and V according to the classification proposed by Dindo et al. was observed in the internal validation. CONCLUSION: This study proposes a prognostic model for the prediction of each grade of postoperative morbidity after liver resection for CLM with high sensitivity and specificity using pre- and intraoperatively available variables.

How Should Deceased Donor Organs Be Allocated? The Patient's Perspective Derived from Semi-Structured Interviews.

Purpose: The gap between the supply and demand for deceased donor organs is increasing worldwide, while patients on waiting lists for organ transplantation die. This situation requires ethical donor organ allocation rules. The patients' perspective on donor organ allocation rules offers a highly relevant and unique perspective that may differ from the perspectives of physicians and the general public. Patients and Methods: Semi-structured telephone interviews were conducted with the regional group coordinators of the federal self-help organization for organ transplanted patients and their relatives in Germany in early 2021. Twelve interviews were conducted with patients and relatives of transplantation patients who received transplants for the affected organs including the lungs, heart, kidney, and liver. Transcripts were analyzed using the deductive framework method which was based on an earlier study. All criteria were reported following the COREQ statement. Results: Participants emphasized aspects of "medical urgency" and "effectiveness/benefit" of transplantation and associated trade-offs as well as the recipient's responsibility for organ failure ("own fault"), the appreciation for the gifted graft and the patient's capability of taking care of it ("appreciation/responsibility"). Patients acknowledged that urgent patients should be prioritized and they showed a clear preference toward allocation rules that strive to maximize both the life years and quality of life gained by transplantation. Conclusion: The patients' perspective is unique in that patients agree on certain rules for allocation and share many preferences, but also have a hard time finding clear cutoff points when considering selecting a participant for allocation. Patient representatives should therefore be consulted in the debate on donor organ allocation rules.

Public preferences for the allocation of donor organs for transplantation: A discrete choice experiment.

This study aimed to assess public preferences for the allocation of donor organs in Germany with the focus on ethical principles of distributive justice. We performed a discrete choice experiment (DCE) using a self-completed online questionnaire. Based on a systematic review and focus group discussions, six attributes, each with two-four levels, were selected (corresponding principle of distributive justice in brackets), including (1) life years gained after transplantation (principle of distributive justice: effectiveness/benefit - utilitarianism), (2) quality of life after transplantation (effectiveness/benefit - utilitarianism), (3) chance for a further donor organ offer (principle of distributive justice: medical urgency - favouring the worst-off), (4) age (medical and social risk factors: sociodemographic status), (5) registered donor (principle of distributive justice: value for society), and (6) individual role in causing organ failure (principle of distributive justice: own fault). Each respondent was presented with eight choice sets and asked to choose between two hypothetical patients without an opt-out. Data were analysed using conditional logit, mixed logit and latent class models. The final sample comprised 1028 respondents. Choice decisions were significantly influenced by all attributes except chance for a further donor organ offer. The attributes of good quality of life after transplantation, younger age, and no individual role in causing organ failure had the greatest impact on choice decisions. Life years gained after transplantation and being a registered donor were less important for the public. The latent class model identified four classes with preference heterogeneities. Respondents preferred to allocate deceased donor organs by criteria related to effectiveness/benefit, whereas medical urgency was of minor importance. Therefore, a public propensity for a rational, utilitarian, ethical model of allocation could be identified. Public preferences can help to inform policy to warrant socially responsible allocation systems and thus improve organ donation rates.

'As a surgeon, I am obliged to every single patient': evaluation of focus group discussions with transplantation physicians on the allocation of donor organs.

INTRODUCTION: Organ transplantation is the last resort for many patients. The ubiquitous shortage of suitable donor organs raises the question of best-justifiable allocation worldwide. This study investigates how physicians would allocate donor organs. METHODS: Focus group discussions with a total of 12 transplant surgeons and 2 other transplant-related physicians were held at the annual conference of the German Transplantation Society (Oct 2019). Three groups discussed aspects of 'egalitarianism', 'effectiveness/benefit', 'medical urgency', 'own fault', 'medical background' and 'socio-demographic status'. RESULTS AND DISCUSSION: It was observed that physicians often find themselves confronted with conflicts between (a) trying to advocate for their individual patients versus (b) seeing the systemic perspective and understanding the global impact of their decisions at the same time. The groups agreed that due to the current shortage of donor organs in the German allocation system, transplanted patients are often too sick at the point of transplantation and that a better balance between urgency and effectiveness is needed. The aspects of 'effectiveness' and 'urgency' were identified as the most challenging issues and thus were the main focus of debate. The dilemmas physicians find themselves in become increasingly severe, the larger the shortage of suitable donor organs is.

Chemotherapy and Hepatic Steatosis: Impact on Postoperative Morbidity and Survival after Liver Resection for Colorectal Liver Metastases.

BACKGROUND: Hepatic steatosis and chemotherapy in the treatment of colorectal liver metastases (CLM) are often linked to increased mortality and morbidity after liver resection. This study evaluates the influence of macrovesicular hepatic steatosis and chemotherapeutic regimes on graded morbidity and mortality after liver resection for CLM. METHODS: A total of 323 cases of liver resection for CLM were retrospectively analysed using univariable and multivariable linear, ordinal and Cox regression analyses. The resected liver tissue was re-evaluated by a single observer to determine the grade and type of hepatic steatosis. RESULTS: Macrovesicular steatosis did not influence postoperative morbidity and survival, as evidenced by risk-adjusted multivariable Cox regression analysis (p = 0.521). Conversion chemotherapy containing oxaliplatin was an independent and significant risk factor for mortality in risk-adjusted multivariable Cox regression analysis (p = 0.005). Identified independently, significant risk factors for postoperative morbidity were neoadjuvant treatment of metastases of the primary tumour with irinotecan (p = 0.003), the duration of surgery in minutes (p = 0.001) and the number of intraoperatively transfused packed red blood cells (p ≤ 0.001). Surprisingly, macrovesicular hepatic steatosis was not a risk factor for postoperative morbidity and was even associated with lower rates of complications (p = 0.006). CONCLUSION: The results emphasize the multifactorial influence of preoperative liver damage and chemotherapy on the severity of postoperative morbidity, as well as the significant impact of conversion chemotherapy containing oxaliplatin on survival.

Systematic review on potential brain dead donor estimations and conversion rates to actually realized organ donations.

INTRODUCTION: Accurate estimations of potential organ donors (POTDs) are required to improve transplant systems. This systematic review analyses current studies on national estimations of potential donors for transplantation as well as the practical and policy implications of detected differences. METHOD: A systematic review of literature published between 01.01.2010 and 01.04.2020 in PubMed was conducted. Data was extracted into a self-developed matrix, and further data retrieved on national population sizes, waiting lists and transplant activities. RESULTS: Six studies were included. Investigated populations, underlying data collections and eligibility criteria for POTDs varied widely. Estimated POTDs per million population (p.m.p.) ranged from 25.8 to 333.6, conversion rates from 3.2% to 47.5% leading to 41.2 to 86.4 transplanted organs p.m.p.. Patients on the waiting lists varied from 66.7 to 338.9 p.m.p., defining gaps between organ supply and demand in countries. Not all studies adhered to the definitions and processes of the critical pathway for deceased donation which is the latest international consensus statement on deceased organ donation. CONCLUSION: Differences in estimated POTDs and differences in supply and demand of donor organs between countries cannot be satisfactorily explained yet due to an obvious lack of evidence, consistent methodology, international consensus and robust underlying datasets. Future studies should be based on robust underlying data sets and aim for potential donor estimations that allow national comparisons due to the adherence to the international consensus on definitions, processes and methodology.

Low-dose steroids do make a difference: Independent risk factors for impaired linear growth after pediatric liver transplantation.

Growth failure persists after pediatric liver transplantation and impairs pediatric development and quality of life. Steroid dose minimization attempts to prevent growth impairment, yet long-term assessment in pediatric liver recipients is lacking. We identified risk factors for impaired linear growth after pediatric liver transplantation, with a special focus on low-dose steroid therapy. This is a single-center retrospective analysis of height development in pediatric liver recipients up to 5 years after transplantation. Risk factors for impaired linear growth (height Z-scores≤-2) at transplantation, after two (n = 347) and five years (n = 210) were identified by univariate and multivariate logistic regression. At transplantation, growth retardation was found in 52.2%, predominantly younger children. Height Z-scores improved from -2.23 to -1.40 (SE 0.11; 95%CI 0.74-1.16; p < .001) two years and -1.19 (SE 0.07;0.08-0.34; p = .017) five years post-transplant. Multivariate analysis showed previous growth impairment (OR=1.484; 95%-CI=1.107-1.988; p = .004), graft loss (49.006;2.232-1076; p = .006), and prolonged cold ischemic time (1.034;1.007-1.061; p = .011) as main long-term risk factors; steroid use was a significant predictor of 2-year but not 5-year growth impairment. In univariate analysis, impaired growth after 2 and 5 years was associated with continuous low-dose (2.5 mg/m2 BSA) steroid therapy (OR=3.323;1.578-6.996; p < .001/OR=8.352;1.089-64.07; p = .006)and graft loss (OR=2.513;1.395-4.525; p = .003/OR=3.378;1.815-7.576; p < .001). Furthermore, indication and era of transplantation affected growth. Our results show significant catch-up growth after pediatric liver transplantation, yet growth failure strongly affects particularly young liver recipients. The main influenceable long-term risk factor is pre-existing growth failure, emphasizing the importance of early aggressive nutritional therapy. Moreover, low-dose steroid therapy might impair growth and should therefore be critically questioned in long-term immunosuppression.

Regression analyses of questionnaires in bedside teaching.

BACKGROUND: Students' ratings of bedside teaching courses are difficult to evaluate and to comprehend. Validated systematic analyses of influences on students' perception and valuation of bedside teaching can serve as the basis for targeted improvements. METHODS: Six hundred seventy-two observations were conducted in different surgical departments. Survey items covered the categories teacher's performance, student's self-perception and organizational structures. Relevant factors for the student overall rating were identified by multivariable linear regression after exclusion of variable correlations > 0.500. The main target for intervention was identified by the 15% worst overall ratings via multivariable logistic regression. RESULTS: According to the students the success of bedside teaching depended on their active participation and the teacher's explanations of pathophysiology. Further items are both relevant to the overall rating and a possible negative perception of the session. In comparison, negative perception of courses (worst 15%) is influenced by fewer variables than overall rating. Variables that appear in both calculations show slight differences in their weighing for their respective endpoints. CONCLUSION: Relevant factors for overall rating and negative perception in bedside teaching can be identified by regression analyses of survey data. Analyses provide the basis for targeted improvement.

Public preferences for the allocation of donor organs for transplantation: Focus group discussions.

BACKGROUND: Deceased donor organs are scarce resources because of a large supply-and-demand mismatch. This scarcity leads to an ethical dilemma, forcing priority-setting of how these organs should be allocated and whom to leave behind. OBJECTIVE: To explore public preferences for the allocation of donor organs in regard to ethical aspects of distributive justice. METHODS: Focus groups were facilitated between November and December 2018 at Hannover Medical School. Participants were recruited locally. Transcripts were assessed with content analysis using the deductive framework method. All identified and discussed criteria were grouped according to the principles of distributive justice and reported following the COREQ statement. RESULTS: Six focus groups with 31 participants were conducted. Overall, no group made a final decision of how to allocate donor organ; however, we observed that not only a single criterion/principle but rather a combination of criteria/principles is relevant. Therefore, the public wants to allocate organs to save as many lives as possible by both maximizing success for and also giving priority to urgent patients considering the best compatibility. Age, waiting time, reciprocity and healthy lifestyles should be used as additional criteria, while sex, financial status and family responsibility should not, based on aspects of equality. CONCLUSIONS: All participants recognized the dilemma that prioritizing one patient might cause another one to die. They discussed mainly the unclear trade-offs between effectiveness/benefit and medical urgency and did not establish an agreement about their importance. The results suggest a need of preference studies to elucidate public preferences in organ allocation.

Optimizing Organ Donation: Expert Opinion from Austria, Germany, Spain and the U.K.

BACKGROUND Organ donation-rates using deceased donors and organizational approaches to organ donation differ drastically between countries at a similar level of health care as measured by the Euro Health Consumer Index (EHCI). MATERIAL AND METHODS Expert opinions from intensive care nurses, physicians, transplant coordinators and transplant surgeons from Austria, Germany, Spain, and the U.K. were obtained in semi-structured interviews followed by qualitative content analysis. Results were reported back to all interview partners to identify potential controversies and consensus recommendations. RESULTS No controversies could be detected. On a variety of beneficial factors an interprofessional consensus between interview partners could be reached: A) The relevance of standardization of the screening for potential donors, the family approach and training; B) standards and best-practice procedures should be regulated and supervised by state authorities; C) full transparency and the prevention of scandals is essential; D) overburdened intensive care unit (ICU) doctors need to be supported by full-time in-house special nurses who organize donor evaluation, transport logistics and pastoral care, if required; E) public awareness campaigns are helpful; F) a broad public consensus on the concept of donation after brain and cardiac death is essential; G) incentives for the reporting of potential organ donors are inappropriate; H) an opt-out system alone is not sufficient. CONCLUSIONS Expert opinions from different professional backgrounds from different European health care systems reach a broad consensus on the most relevant issues for the improvement of organ donation.