WORKSHOP ON INCREASING RATES ON ORGAN DONATION -INSTITUTE OF MEDICINE-

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1 WORKSHOP ON INCREASING RATES ON ORGAN DONATION -INSTITUTE OF MEDICINE- RAFAEL MATESANZ DIRECTOR ONT - SPAIN (SPANISH NATIONAL TRANSPLANT ORGANIZATION)

2 UNIVERSAL PROBLEM

3

4 30 SPAIN 30 USA ITALY SCANDINAVIA UNITED KINGDOM EUROTRANSPLANT 0 ORGAN DONATION RATE EVOLUTION:

5 30 DONORS PMP 20 DONORS PMP 10 DONORS PMP 16,7 <10 DONORS PMP 19, ,1 34, ,9, 13,05 ORGAN DONORS p.m.p , ,

6 During the eighties......things were not so easy

7 ORGAN DONOR IN SPAIN SINCE THE START OF O.N.T NUMBER RATE pmp ,5 33,9 33,6 33,7 33,9 34,6 32, , ,7 22,6 20, , ,

8 RENAL TRANSPLANTS IN SPAIN

9 RENAL WAITING LIST IN SPAIN

10 LIVER TRANSPLANTS

11 PHILOSOPHY OF THE SPANISH MODEL IMPROVEMENT OF ORGAN DONATION IMPROVEMENT OF ORGANIZATION

12 CLASSIC APPROACHES TO IMPROVE ORGAN DONATION Changes of Legislation Publicity Campaigns Donor Registries Donor Cards / Driving Licenses Other ways of promotion...

13 BASIC PRINCIPLES OF THE SPANISH MODEL Adequate legal and technical background Transplant coordination network Special profile of the three levels of TC Hospital coordinators inside the hospitals Continuous brain death audit Central Office: ONT - Support Agency Great effort in medical training Hospital reimbursement Much attention to the mass media ALL THESE POINTS TOGETHER!

14 R REGIONAL R H H R H NATIONAL H HOSPITAL TRANSPLANT COORDINATION NETWORK R

15 TRANSPLANT COORDINATION NETWORK R REGIONAL R INTERFACES: ADMINISTRATIVE R NATIONAL PROFESSIONAL LEVELS R

16 NUMBER OF TRANSPLANT COORDINATION TEAMS <

17 COORDINATOR PROFILE Medical doctors +/- nurses Part time dedicated ICU +/- NEPHROLOGISTS... Dependency: medical director Main objective: Organ donation More and more involved in: Resources management Mass media Logistic support of the process...

18 T.C. TRANSPLANT COORDINATORS INSIDE THE HOSPITALS T.C. T.C. T.C.

19 42 HOSPITALS WITH TRANSPLANT TEAMS % OF THE DONORS (20 DONORS pmp) 62% 91 HOSPITALS WITHOUT TRANSPLANT TEAMS % OF THE DONORS (14 DONORS pmp) 38%

20 BURN OUT SYNDROME CHANGE DONORS NEW COORDINATOR YEARS

21 RENAL TRANS PLANTS REGION OF MADRID YEAR-TO-YEAR RATE NUMBER NEW ROAD TRAFFIC LAW NEW CHANGE CHANGE OF COORDINATORS

22 QUALITY PROGRAMME IN ORGAN DONATION A 5 YEARS ON LINE CHART REVIEW ALL SPANISH REGIONS: 118 HOSPITALS DEATHS IN ICU BRAIN DEATHS (12,2%/ ICU - DEATHS) 4987 ACTUAL DONORS (49% OF BRAIN DEATHS) QUALITY PROGRAMME IN ORGAN DONATION AREAS FOR IMPROVEMENT: FAMILY REFUSAL:...20% BRAIN DEATH DETECTION:...3,1% DONOR MAINTENANCE :... 2,7% OTHER...1,5 3% TOTAL %

23 CENTRAL OFFICE AS A SUPPORT AGENCY IN FAVOUR OF ORGAN DONATION NOT JUST A SHARING OFFICE

24 GREAT EFFORT IN MEDICAL TRAINING

25 HOSPITAL REIMBURSEMENT (ESTIMATED MEAN VALUES) Multi-organ procurement Renal procurement Multi-organ + tissue EUROS ( ) hour of operating room: )

26 HEALTH SPENDING/PERSON IN EUROPE AND USA ($) $/PERSON/YEAR USA GERMANY FRANCE HOLAND SWEDEN BELGIUM AUSTRIA ITALY PORTUGAL SPAIN

27 42 HOSPITALS WITH TRANSPLANT TEAMS % OF THE DONORS (20 DONORS pmp) 62% 91 HOSPITALS WITHOUT TRANSPLANT TEAMS % OF THE DONORS (14 DONORS pmp) 38%

28

29 DONOR DETECTION DONOR MAINTENANCE TRANSPLANTS P R O C U R E M E N T LOCAL AND ORGA NISATIONAL FA CTORS BRAIN DEATH DIAGNOSIS FAMILY & LEGAL CONSENT

30 QUALITY PROGRAMME IN ORGAN DONATION A 5 YEARS ON LINE CHART REVIEW ALL SPANISH REGIONS: 118 HOSPITALS DEATHS IN ICU BRAIN DEATHS (12,2%/ ICU - DEATHS) 4987 ACTUAL DONORS (49% OF BRAIN DEATHS) QUALITY PROGRAMME IN ORGAN DONATION AREAS FOR IMPROVEMENT: FAMILY REFUSAL:...20% BRAIN DEATH DETECTION:...3,1% DONOR MAINTENANCE :... 2,7% OTHER...1,5 3% TOTAL %

31 DURING 2004, THE FAMILY REFUSALS WENT UNDER 20% FOR THE FIRST TIME % % FAMILY REFUSALS

32 NUMBER OF INTERVIEWS FAMILY REFUSALS REFUSALS / NUMBER OF INTERVIEWS

33 CLINICAL PRACTICE VARIABILITY: 70% MEDICAL CONTRAINDICATIONS vs BRAIN DEATHS 60% 50% 40% 30% 20% 10% 0% HOSPITALS

34 CLINICAL PRACTICE VARIABILITY: 90 MAXIMUM AGE OF ACTUAL DONORS IN DIFFERENT HOSPITALS MAXIMUM AGE NUMBER OF DONORS

35 EDAD MÁXIMA MAXIMUM AGE 70 ACTUAL DONORS vs BRAIN DEATHS. MAXIMUM AGE BRAIN DEATHS MUERTES ENCEFÁLICAS ACTUAL DONORS DONANTES REALES HOSPITALS TYPE 1 & 2

36

37 PERCENTAGE OF THE POPULATION OVER 60 YEARS % SPAIN ITALY TUSCANY UNITED KINGDOM MEAN EU USA

38 <15 ye ars years years years >60 years 100% 80% 60% 40% 20% EVOLUTION OF THE AGE OF DONORS DURING THE LAST DECADE 0% >60 years 10 11, , ,3 31,3 33,9 34,4 33,8 37, years 21 31, ,6 25,8 27,1 26,5 28,1 28,8 29,7 28,3 29, years 25 20, ,8 21,9 19,4 19,2 17,1 16,3 15,7 16,3 14, years ,5 22,8 19,5 20,5 19,6 19,6 17,8 15,1 16,9 13 <15 years 10 9, ,7 5,8 5,7 4,4 3,9 3,2 5,2 4,7 4,6

39 DEATHS DUE TO ROAD TRAFFIC ACCIDENTS SPAIN

40 100% 80% 39% 46 % 48% 49% 51% 55.3%53.5% 55.4% 56.3%59.9% 59,5% 56.4% 59.9% 60% 40% 20% 43% 35 % 28% 29% 25.6%23.4% 24.9% 23.% 21.3 % 20,2 % 17,5 %20,3 % 15,6 % 0% TRAFFIC ACC. NON TRAFF. ACC CEREBRAL BLEEDING OTHER

41 GROUPS OF DONORS AND RECIPIENTS CADAVERIC KIDNEY TRANSPLANTS 100% 80% 60% 40% 20% 0% p < 0,00001 Donors < 60 years Recipient < 60 years Recipient > 60 years Donors > 60 years Recipient < 60 years Recipient > 60 years

42 CADAVERIC KIDNEY GRAFT SURVIVAL ACCORDING TO THE AGE OF DONOR AND RECIPIENT DONOR <60 DONOR >60 RECIPIENT < 60 YEARS RECIPIENT > 60 YEARS RECIPIENT < 60 YEARS RECIPIENT > 60 YEARS

43 LIVER GRAFT SURVIVAL ACCORDING TO THE AGE OF THE DONOR NON URGENT TRANSPLANTS GLOBAL WILCOXON TEST p < 0,01 p < 0,05 FOR ALL BUT 75 vs y YEARS AGE OF THE DONOR

44 > >35 > ORGAN DONORS PMP SPANISH REGIONS

45

46 ORGAN DONORS IN TUSCANY - ITALY ORGAN DONORS p.m.p. 36 DONORS p.m.p

47 19, DONORS PMP ORGAN DONATION IN URUGUAY

48 Procuración y Trasplantes 2003 E F M A M J J A S O N D 7.5 Don. Reales ORGAN DONATION IN ARGENTINA PROGRAMME OF COOPERATION Don Tejidos Tx Renales DONORS PMP Tx. Totales Don. Reales0 Don Tejidos Tx Renales Tx. Totales E 04 F M A M J J A

49 ESTIMATED COSTS OF SOLID ORGAN TRANSPLANTS IN SPAIN ORGAN PROCUREMENT RENAL TRANSPLANTS LIVER TRANSPLANTS HEART TRANSPLANTS LUNG TRANSPLANTS OTHER (PANCREAS, etc) PER UNIT TOTAL ONT STRUCTURE TOTAL ,7%

50 renal patients transplanted thanks to this system

51 PATIENTS ORGAN PROCUREMENT RENAL TRANSPLANTS LIVER TRANSPLANTS HEART TRANSPLANTS LUNG TRANSPLANTS OTHER (PANCREAS, etc) COORDINATION NETWORK TOTAL PER UNIT TOTAL

52 CONCLUSIONS The Spanish Model results from the efforts of many to overcome obstacles such as untrained or under trained requesting staff, unidentified donors and the reluctance to approach grieving family members.

53 CONCLUSIONS...Organ shortage is not due to a lack of potential donors, but rather to a failure to Turn many potential into actual donors The Spanish Model can be partial or totally extrapolated to other countries/regions, provided adequate measures are taken.

54

55 ORGAN DONATION AND TRANSPLANTATION DURING THE FIRST 5 MONTS OF 2005 DONORS +5,9% KIDNEY TX. +3,9% LIVER TX. +6,4% HEART TX. +10,5% PANCREAS TX +90%

56 MEDICAL DOCTORS/1000 INHABIT DOCTORS 1 0 IT GRE FRA JAP SP SWE USA U.K.

57 AVERAGE PAY PER YEAR FOR DOCTORS ( ) U.K. SWEEDEN SPAIN GREECE 0 SENIORS JUNIORS

58 NUMBER OF NURSES / 1000 INHABITANTS ITA GRE SWE U.K. SPAIN FRAN. FIN. NURSES

59 NUMBER OF NURSES / HOSPITAL BED 3 2,5 2 1,5 1 NURSES/HOSP. BED 0,5 0 IT GRE FIN U.K. SPAIN FRAN SWE

60 NUMBER OF I.C.U. BEDS / INHAB. ICU BEDS/ 1000 INHAB SWEEDEN GREECE TUSCANY ITALY SPAIN 81,2 53,4 73,4 6O,4 66, UNITED KINGDOM 33,6

61 ACUTE HOSPITAL BEDS / 1000 INHAB HOSPITAL BEDS SPAIN ITALY TUSCANY UNITED KINGDOM GREECE SWEDEN U.S.A.

62 PERCENTAGE I.C.U. BEDS / HOSPITAL BEDS 3 2,5 2 1,5 1 0,5 0 % ICU BEDS / HOSPITAL BEDS SPAIN ITALY TUSCANY AUSTRIA UNITED KINGDOM GREECE SWEDEN

63 CADAVERIC KIDNEY GRAFT SURVIVAL ACOORDING TO THE AGE OF THE DONOR YEAR AGE OF THE DONOR

64 100 PERCENTAGE ACTUARIAL KIDNEY GRAFT SURVIVAL ACCORDING TO THE RECIPIENT S AGE Years <55 y y y y >69 y

65 KIDNEY GRAFT SURVIVAL DEPENDING ON THE PERIOD OF GRAFTING

66 FIRST LIVER GRAFT SURVIVAL ACCORDING TO THE AGE OF THE DONOR GLOBAL Wilcoxon Test p < 0, years vs other p < 0,05 AGE OF THE DONOR 70 YEARS YEARS YEARS YEARS YEAR

67 LIVER GRAFT SURVIVAL (ALL) ACCORDING TO THE YEAR OF TRANSPLANTATION GLOBAL Wilcoxon Test p < 0,001 p < 0,05 FOR ALL BUT vs y vs YEAR OF TRANSPLANT

68 CHARACTERISTICS OF RECIPIENTS ACCORDING TO THE AGE OF THE DONORS AGE OF THE DONOR YEARS YEARS >70 YEARS (2756) (1785) (433) p MEAN AGE RECIPIENT (YEARS) 50,5 52,9 55,2 < 0,05 HEPATOCARCINOMA (RECIPIENT) 18,4% 18,3% 23,9% < 0,05 VIRUS C HEPATITIS (RECIPIENT) 37,9% 40,0% 45,4% < 0,05 RECIPIENT IN HOSPITAL 9,5% 9,2% 11,7% < 0,05 ISQUEMIA TIME (MIN.) < 0,05 PRIMARY MALFUNCTION 1,90% 2,20% 2,10% > 0,05 RECIDIVE OF PRIMARY DISEASE 17,6% 23,0% 29,7% < 0,05

69 Graft survival (deaths censored) by recipient s age Percentage Years <55 y y y y >69 y

70 HOSPITAL REIMBURSEMENT (ESTIMATION OF COST ) CARDIAC TRANSPLANT RENAL TRANSPLANT LIVER TRANSPLANT BONE MARROW TRANSPLANT LUNG TRANSPLANT Diagnosisrelated groups (D.R.G.) 31,91 8,81 33,56 24,49 Estimated ESTIMATED COST ( )

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