WORKSHOP ON INCREASING RATES ON ORGAN DONATION -INSTITUTE OF MEDICINE- RAFAEL MATESANZ DIRECTOR ONT - SPAIN (SPANISH NATIONAL TRANSPLANT ORGANIZATION)
UNIVERSAL PROBLEM
30 SPAIN 30 USA 20 10 20 ITALY SCANDINAVIA UNITED KINGDOM EUROTRANSPLANT 0 ORGAN DONATION RATE EVOLUTION: 1989-2003 1989 2003 0
30 DONORS PMP 20 DONORS PMP 10 DONORS PMP 16,7 <10 DONORS PMP 19,6 20.9 22.2 22,1 34,6 13.8 21 21.8 15.5 12.6 11,9, 13,05 ORGAN DONORS p.m.p. 2004 2 18 21.1 13.7 20.5 22.6 14,7 10.2 16 13.6 17.8 6 10.3 0,5 2 8.8
During the eighties......things were not so easy
ORGAN DONOR IN SPAIN SINCE THE START OF O.N.T. 1600 40 NUMBER RATE pmp 1400 31,5 33,9 33,6 33,7 33,9 34,6 32,5 35 29 1200 25 27 26,8 30 21,7 22,6 20,2 1000 25 17,8 800 20 14,3 600 400 687 869 778 832 960 14481494 1410 13451335 12501334 15 1155 10371032 10 550 200 5 0 0 1989 1991 1993 1995 1997 1999 2001 2003
2100 1900 1700 1500 1300 1100 900 1182 987 1017 1039 1371 1240 2131 2125 1492 1488 1633 1996 2023 1938 1924 2032 1800 1857 1707 RENAL TRANSPLANTS IN SPAIN 1986 1987 1988 1989 1990 1991 2003 2004 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
4035 3850 3922 39864014 3933 RENAL WAITING LIST IN SPAIN 6000 5593 51515097 5000 4603 44674444 4000 3000 2000 1000 0 91 92 93 94 95 96 97 98 1999 2000 2001 2002 2003
1100 900 700 500 300 100-100 14 5 44 50 123 170 313 412 468 495 614 698 700 790 899 LIVER TRANSPLANTS 960 954 972 103310371040 1999 2000 2001 2002 2003 2004 1998 1996 1997 1995 1993 1994 1992 1991 1989 1990 1985 1986 1987 1988 1984
PHILOSOPHY OF THE SPANISH MODEL IMPROVEMENT OF ORGAN DONATION IMPROVEMENT OF ORGANIZATION
CLASSIC APPROACHES TO IMPROVE ORGAN DONATION Changes of Legislation Publicity Campaigns Donor Registries Donor Cards / Driving Licenses Other ways of promotion...
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!
R REGIONAL R H H R H NATIONAL H HOSPITAL TRANSPLANT COORDINATION NETWORK R
TRANSPLANT COORDINATION NETWORK R REGIONAL R INTERFACES: ADMINISTRATIVE R NATIONAL PROFESSIONAL LEVELS R
NUMBER OF TRANSPLANT COORDINATION TEAMS < 20 56 118 139 1988 1990 1992 1998
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...
T.C. TRANSPLANT COORDINATORS INSIDE THE HOSPITALS T.C. T.C. T.C.
42 HOSPITALS WITH TRANSPLANT TEAMS -------------- 62% OF THE DONORS (20 DONORS pmp) 62% 91 HOSPITALS WITHOUT TRANSPLANT TEAMS ----------------------- 38% OF THE DONORS (14 DONORS pmp) 38%
BURN OUT SYNDROME CHANGE DONORS NEW COORDINATOR YEARS
RENAL TRANS PLANTS REGION OF MADRID YEAR-TO-YEAR RATE NUMBER NEW ROAD TRAFFIC LAW NEW CHANGE CHANGE OF COORDINATORS
QUALITY PROGRAMME IN ORGAN DONATION A 5 YEARS ON LINE CHART REVIEW ALL SPANISH REGIONS: 118 HOSPITALS 83.420 DEATHS IN ICU 10175 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...25-30%
CENTRAL OFFICE AS A SUPPORT AGENCY IN FAVOUR OF ORGAN DONATION NOT JUST A SHARING OFFICE
GREAT EFFORT IN MEDICAL TRAINING
HOSPITAL REIMBURSEMENT (ESTIMATED MEAN VALUES) Multi-organ procurement Renal procurement Multi-organ + tissue EUROS ( ) 6.000 4.500 7.500 1 hour of operating room: 1.500 )
6000 5000 4000 3000 2000 1000 0 HEALTH SPENDING/PERSON IN EUROPE AND USA- 2002 ($) $/PERSON/YEAR USA GERMANY FRANCE HOLAND SWEDEN BELGIUM AUSTRIA ITALY PORTUGAL SPAIN
42 HOSPITALS WITH TRANSPLANT TEAMS -------------- 62% OF THE DONORS (20 DONORS pmp) 62% 91 HOSPITALS WITHOUT TRANSPLANT TEAMS ----------------------- 38% OF THE DONORS (14 DONORS pmp) 38%
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
QUALITY PROGRAMME IN ORGAN DONATION A 5 YEARS ON LINE CHART REVIEW ALL SPANISH REGIONS: 118 HOSPITALS 83.420 DEATHS IN ICU 10175 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...25-30%
DURING 2004, THE FAMILY REFUSALS WENT UNDER 20% FOR THE FIRST TIME 30 25 20 20% 15 10 5 2004 17.8% 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 FAMILY REFUSALS
2000 1800 1600 1400 1200 1170 1232 1443 1562 1648 1643 1735 1849 1893 1871 1952 1940 1974 1000 800 600 400 323 308 341 387 409 358 370 404 418 438 391 388 351 200 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 NUMBER OF INTERVIEWS FAMILY REFUSALS REFUSALS / NUMBER OF INTERVIEWS
CLINICAL PRACTICE VARIABILITY: 70% MEDICAL CONTRAINDICATIONS vs BRAIN DEATHS 60% 50% 40% 30% 20% 10% 0% 86 5 27 36 4 28 19 25 70 18 28 22 19 48 21 32 55 19 28 49 42 53 48 29 46 68 51 54 54 29 13 5 HOSPITALS
CLINICAL PRACTICE VARIABILITY: 90 MAXIMUM AGE OF ACTUAL DONORS IN DIFFERENT HOSPITALS 80 83 70 60 65 66 67 68 69 69 69 70 71 71 71 71 72 73 73 74 75 75 75 77 77 78 78 78 79 79 79 MAXIMUM AGE 59 57 50 28 21 27 36 49 22 32 54 42 18 55 19 29 70 5 48 13 28 46 29 19 86 25 51 54 19 28 68 48 53 NUMBER OF DONORS
EDAD MÁXIMA 90 80 MAXIMUM AGE 70 ACTUAL DONORS vs BRAIN DEATHS. MAXIMUM AGE 89 86 86 85 84 83 82 82 83 81 80 80 79 79 83 78 78 78 77 76 76 75 75 76 75 79 79 79 74 78 78 78 73 73 77 77 72 71 71 75 75 75 74 73 73 72 71 71 71 71 70 69 69 69 68 67 66 65 60 50 59 57 BRAIN DEATHS MUERTES ENCEFÁLICAS ACTUAL DONORS DONANTES REALES 28 27 49 32 42 55 29 5 13 46 19 25 54 28 48 HOSPITALS TYPE 1 & 2
PERCENTAGE OF THE POPULATION OVER 60 YEARS 30 25 20 15 10 5 0 % SPAIN ITALY TUSCANY UNITED KINGDOM MEAN EU USA
<15 ye ars 15-30 years 30-45 years 45-60 years >60 years 100% 80% 60% 40% 20% EVOLUTION OF THE AGE OF DONORS DURING THE LAST DECADE 0% 199 2 199 3 199 4 199 4 199 6 199 7 199 8 199 9 200 0 200 1 200 2 200 3 200 4 >60 years 10 11,5 17 20,5 22 28 27 30,3 31,3 33,9 34,4 33,8 37,9 45-60 years 21 31,5 28 30 27,6 25,8 27,1 26,5 28,1 28,8 29,7 28,3 29,8 30-45 years 25 20,5 23 20 19,8 21,9 19,4 19,2 17,1 16,3 15,7 16,3 14,7 15-30 years 34 27 23 22,5 22,8 19,5 20,5 19,6 19,6 17,8 15,1 16,9 13 <15 years 10 9,5 9 7 7,7 5,8 5,7 4,4 3,9 3,2 5,2 4,7 4,6
DEATHS DUE TO ROAD TRAFFIC ACCIDENTS SPAIN
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% 1992 1994 1996 1998 2000 2002 2004 TRAFFIC ACC. NON TRAFF. ACC CEREBRAL BLEEDING OTHER
GROUPS OF DONORS AND RECIPIENTS 1990-2001 CADAVERIC KIDNEY TRANSPLANTS 100% 80% 60% 40% 20% 0% 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 p < 0,00001 Donors < 60 years Recipient < 60 years Recipient > 60 years Donors > 60 years Recipient < 60 years Recipient > 60 years
CADAVERIC KIDNEY GRAFT SURVIVAL ACCORDING TO THE AGE OF DONOR AND RECIPIENT-1990-2001 DONOR <60 DONOR >60 RECIPIENT < 60 YEARS RECIPIENT > 60 YEARS RECIPIENT < 60 YEARS RECIPIENT > 60 YEARS
LIVER GRAFT SURVIVAL ACCORDING TO THE AGE OF THE DONOR NON URGENT TRANSPLANTS 1991-2002 GLOBAL WILCOXON TEST p < 0,01 p < 0,05 FOR ALL BUT 75 vs 35-54 y 55-74 YEARS AGE OF THE DONOR
28.7 47.5 46.9 47.7 41.0 >40 20.4 30.5 37.9 27.2 >35 >30 21.4 31.5 24.9 36.5 46.1 33.2 37.8 34.6 35.5 ORGAN DONORS PMP- 2004 SPANISH REGIONS
ORGAN DONORS IN TUSCANY - ITALY 140 120 100 80 60 40 20 ORGAN DONORS p.m.p. 36 DONORS p.m.p. 0 1997 1999 2001 2003
19,3 20 15 10 0 5 DONORS PMP 2001 02 03 04 ORGAN DONATION IN URUGUAY
110 100 90 80 70 60 50 40 30 20 10 0 10 Procuración y Trasplantes 2003 E F M A M J J A S O N D 7.5 Don. Reales 20 20 23 24 10 18 19 26 34 41 29 37 29 33 33 37 37 23 40 32 5 ORGAN DONATION IN ARGENTINA PROGRAMME OF COOPERATION Don Tejidos 32 28 20 20 35 26 26 28 44 55 55 45 34 40 48 36 45 37 37 35 Tx Renales 25 29 31 37 16 24 22 38 58 63 45 60 43 43 59 60 49 35 60 43 2.5 DONORS PMP Tx. Totales 39 38 55 56 28 46 35 69 94 93 73 90 66 79 101 88 71 52 85 70 Don. Reales0 Don Tejidos Tx Renales Tx. Totales 2001 02 03 04 E 04 F M A M J J A
ESTIMATED COSTS OF SOLID ORGAN TRANSPLANTS IN SPAIN ORGAN PROCUREMENT RENAL TRANSPLANTS LIVER TRANSPLANTS HEART TRANSPLANTS LUNG TRANSPLANTS OTHER (PANCREAS, etc) PER UNIT 16537 62995 59898 45181 TOTAL 8.975.903 33.433735 56.626506 20.126506 6.096.385 674.699 ONT STRUCTURE TOTAL 4.939.759 130.873.493 3,7%
2100 1996 2023 1938 1924 2032 2132 2125 1900 1800 1857 1700 1633 1707 1500 1300 1182 1240 1371 1492 1488 + 12.000 renal patients transplanted thanks to this system 1100 987 1017 1039 900 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
12.000 PATIENTS ORGAN PROCUREMENT RENAL TRANSPLANTS LIVER TRANSPLANTS HEART TRANSPLANTS LUNG TRANSPLANTS OTHER (PANCREAS, etc) COORDINATION NETWORK TOTAL PER UNIT 16537 62995 59898 45181 TOTAL 8.975.903 33.433735 56.626506 20.126506 6.096.385 674.699 4.939.759 130.873.493
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.
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.
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%
MEDICAL DOCTORS/1000 INHABIT. 6 5 4 3 2 DOCTORS 1 0 IT GRE FRA JAP SP SWE USA U.K.
AVERAGE PAY PER YEAR FOR DOCTORS ( ) 120000 100000 80000 60000 40000 20000 U.K. SWEEDEN SPAIN GREECE 0 SENIORS JUNIORS
NUMBER OF NURSES / 1000 INHABITANTS 16 14 12 10 8 6 4 2 0 ITA GRE SWE U.K. SPAIN FRAN. FIN. NURSES
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
NUMBER OF I.C.U. BEDS / 1.000.000 INHAB. ICU BEDS/ 1000 INHAB SWEEDEN GREECE TUSCANY ITALY SPAIN 81,2 53,4 73,4 6O,4 66,3 0 50 100 UNITED KINGDOM 33,6
ACUTE HOSPITAL BEDS / 1000 INHAB. 6 5 4 3 2 1 0 HOSPITAL BEDS SPAIN ITALY TUSCANY UNITED KINGDOM GREECE SWEDEN U.S.A.
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
CADAVERIC KIDNEY GRAFT SURVIVAL ACOORDING TO THE AGE OF THE DONOR - 1990-2001 YEAR AGE OF THE DONOR
100 PERCENTAGE ACTUARIAL KIDNEY GRAFT SURVIVAL ACCORDING TO THE RECIPIENT S AGE 1990-2001 80 60 40 20 0 0 2 4 6 8 10 Years <55 y 55-59 y 60-64 y 65-69 y >69 y
KIDNEY GRAFT SURVIVAL DEPENDING ON THE PERIOD OF GRAFTING 1998-2003 1986-1997 1980-1985
FIRST LIVER GRAFT SURVIVAL ACCORDING TO THE AGE OF THE DONOR 1993-2002 GLOBAL Wilcoxon Test p < 0,01 15-49 years vs other p < 0,05 AGE OF THE DONOR 70 YEARS 60-69 YEARS 50-59 YEARS 16-49 YEARS YEAR
LIVER GRAFT SURVIVAL (ALL) ACCORDING TO THE YEAR OF TRANSPLANTATION 1984-2002 GLOBAL Wilcoxon Test p < 0,001 p < 0,05 FOR ALL BUT 1984-1987 vs 1988-1990 y 1991-1993 vs 1994-1996 YEAR OF TRANSPLANT
CHARACTERISTICS OF RECIPIENTS ACCORDING TO THE AGE OF THE DONORS AGE OF THE DONOR 16-49 YEARS 50-69 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.) 418 397 366 < 0,05 PRIMARY MALFUNCTION 1,90% 2,20% 2,10% > 0,05 RECIDIVE OF PRIMARY DISEASE 17,6% 23,0% 29,7% < 0,05
Graft survival (deaths censored) by recipient s age. 1990-2001 100 Percentage 80 60 40 20 0 0 2 4 6 8 10 Years <55 y 55-59 y 60-64 y 65-69 y >69 y
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 ( ) 59898 16537 62995 45970 45181