Correspondence

Estimating the Number of Potential Organ Donors in the United States

N Engl J Med 2003; 349:2073-2075November 20, 2003

Article

To the Editor:

Sheehy et al. (Aug. 14 issue)1 show the relevance of studying the pool of brain-dead potential organ donors. Similar studies conducted in Spain during the past 10 years have resulted in increases in the actual rates of donation, making the rate in our country the highest in the world.2

The two main causes of the loss of donors are similar worldwide: low rates of identification or referral of brain-dead patients and refusal by the family.3 To address both of these causes, it is essential to collaborate with transplantation coordinators in hospitals, regardless of the size of the hospital. More than a third of the actual organ donors in Spain come from small hospitals without neurosurgery facilities or transplantation programs.4 Ongoing training programs for transplantation coordinators (particularly in the obtaining of consent from families) are essential.

Interventions designed to increase social awareness, legislative changes, and financial incentives for the families of donors are unpredictable, complex, and expensive approaches. Many simple and inexpensive solutions that can increase the rate of donation await exploration in hospitals.

Miguel A. Frutos, M.D.
Carlos Haya University Hospital, Malaga 29010, Spain
mangel.frutos.sspa@juntadeandalucia.es

Manuel Alonso, M.D.
Andalusian Health Service, Seville 41007, Spain

4 References

1. 1

   Sheehy E, Conrad SL, Brigham LE, et al. Estimating the number of potential organ donors in the United States. N Engl J Med 2003;349:704-706
   Full Text | Web of Science | Medline

2. 2

   Organización Nacional de Trasplantes home page. (Accessed October 29, 2003, at http://www.msc.es/ont/esp/estadisticas/f_estadisticas.htm.)
   

3. 3

   Frutos MA, Ruiz P, Requena MV, Daga D. Family refusal in organ donation: analysis of three patterns. Transplant Proc 2002;34:2513-2514
   CrossRef | Web of Science | Medline

4. 4

   Calidad. (Accessed October 29, 2003, at http://www.msc.es/ont/esp/calidad/f_calidad.htm.)
   

To the Editor:

Sheehy et al. state that studies based on mortality data are considered inferior to those using chart reviews, because they provide insufficient information to permit the evaluation of contraindications to organ donation.1-3 However, retrospective audits of medical files also require the systematic recording of brain death and coexisting conditions. They are time-consuming and labor-intensive and must be repeated or conducted prospectively, as they were in Spain.4 Hospital mortality statistics do not provide exhaustive data concerning contraindications to donation, but their use could simplify the estimation of the number of potential donors for public health authorities and hospital coordinators. The number of potential donors could also be determined according to the principal causes of brain death, which are rarely reported.3 Such reporting would require the creation of a specific code for brain death in the International Classification of Diseases that would facilitate studies and comparisons based on mortality data5; the creation of such a code could be justified by the importance of estimating the number of potential donors in industrialized countries in which there is a shortage of organs for transplantation.

Philippe Tuppin, M.D., Ph.D.
Fabienne Pessione, M.D.
Etablissement Français des Greffes, Paris 75012, France
ptuppin001@efg.atrium.rss.fr

5 References

1. 1

   Ojo AO, Wolfe RA, Leichtman AB, Dickinson DM, Port FK, Young EW. A practical approach to evaluate the potential donor pool and trends in cadaveric kidney donation. Transplantation 1999;67:548-556
   CrossRef | Web of Science | Medline

2. 2

   Evans RW, Orians CE, Ascher NL. The potential supply of organ donors: an assessment of the efficacy of organ procurement efforts in the United States. JAMA 1992;267:239-246
   CrossRef | Web of Science | Medline

3. 3

   Holt AW, Hodgemen GK, Vedig AE, Heard PE. Organ donor index: a benchmark for comparing hospital organ donor rates. Med J Aust 1999;170:479-481
   Web of Science | Medline

4. 4

   Cuende Melero N, Canon Campos JF, Miranda Serrano B, Alonso Gil M. The organ donation process: a program for its evaluation and improvement. Organs Tissues 2002;2:109-118
   

5. 5

   Palo J, Viitala S. Diagnosis and frequency of brain death. Lancet 1999;354:1909-1910
   CrossRef | Web of Science | Medline

To the Editor:

I agree with Sheehy et al. that evaluating the performance of organ-procurement organizations on the basis of the rate of conversion of potential donors into actual ones is preferable to evaluation on the basis of the number of donors per million population. However, there is a serious problem with the use of average conversion rates to gauge the performance of these organizations. One of the major factors affecting conversion rates is the rate of consent by the family, and this rate varies widely among organ-procurement organizations. Although variations in the consent rates could reflect the varying quality of the organ-procurement organizations, variations in the demographics of the populations served might be responsible. For example, some studies have found that some racial groups are more likely than others to consent to organ donation.1 Thus, consent and conversion rates may vary from region to region independently of the quality of work of the organ-procurement organizations. Assessments of the performance of these organizations should be based on conversion rates that have been corrected for demographic factors that may affect consent rates.

Aaron Spital, M.D.
University of Rochester School of Medicine, Rochester, NY 14642
aaron_spital@urmc.rochester.edu

1 References

1. 1

   Siminoff LA, Gordon N, Hewlett J, Arnold RM. Factors influencing families' consent for donation of solid organs for transplantation. JAMA 2001;286:71-77
   CrossRef | Web of Science | Medline

Author/Editor Response

Few would deny that Spain has done a superb job of increasing the number of organ donors over the past decade. It is difficult, however, to compare countries in terms of performance, since there are no uniform data available on the potential for organ donation according to country. The assertion by Drs. Frutos and Alonso that Spain has the highest rate of donation in the world appears to be based on the measurement of the number of donors per million living population. Our study highlighted the fact that this measurement is only weakly correlated with the number of potential donors who become actual donors, which calls into question the usefulness of the measurement for the assessment of performance among different organ-procurement organizations or different geographic regions.

We agree with the assessment by Drs. Frutos and Alonso that working inside hospitals holds the most promise for increasing the number of organ donors from traditional sources. Our experience in the United States regarding the location of potential and actual donors differs from the experience in Spain. We found little potential for donation in small hospitals: 80 percent of the potential organ donors were concentrated in 19 percent of hospitals in the United States. Organ-donor potential was correlated with hospital size (the number of beds) and with the presence or absence of a neurosurgical service in the hospital.

Drs. Tuppin and Pessione make the intriguing and valuable recommendation that a specific code be created for brain death in the International Classification of Diseases. We would welcome the implementation of such a code, which would undoubtedly allow for improved analysis of hospital mortality statistics and permit much better estimates of organ-donor potential according to organ-procurement organization and country. Even with such a new code, we would anticipate that organ-procurement organizations would continue to collect patient-level data on organ-donor potential from referrals and from hospital charts to inform their strategies for individual hospitals. Chart reviews do require staff time, but with more and more hospital referrals and sophisticated data collection at the time of referral, the burden of conducting chart reviews has diminished substantially.

The explanation of variations in performance among organ-procurement organizations is certainly complicated, and Dr. Spital points out the importance of taking account of differences in the demographics of the underlying pool of potential donors from one service area to another. Although consent rates do vary significantly according to racial group, the challenge for the organ-procurement community is to continue to work to improve the consent rate across the board.

Ellen Sheehy, M.P.P.M., M.A.R.
Association of Organ Procurement Organizations, McLean, VA 22101
organdonation@aopo.org

Suzanne L. Conrad, M.S.
Iowa Donor Network, Iowa City, IA 52242

Lawrence Hunsicker, M.D.
University of Iowa, Iowa City, IA 52246

Citing Articles (1)

Citing Articles

1. 1

   R. D. Friele, R. Coppen, R. L. Marquet, J. K.M. Gevers. (2006) Explaining Differences Between Hospitals in Number of Organ Donors. American Journal of Transplantation 6:3, 539-543
   CrossRef