Conference Report: Increasing Organ Donation and Transplantation: The Challenge of Evaluation. Panel 5: Expanded Donor Criteria

04/02/1998

This panel included presentations on initiatives designed to improve the organ donation rate, either by expanding the criteria that have traditionally defined the donor pool or by novel measures to achieve greater conversion rates among those who are already recognized as potential donors. As in the programs detailed in the previous panel, these efforts are hospital-level initiatives and thus lend themselves to evaluations using donation rates and post-event intermediate measures that are proximal to donation rates. However, they also have faced unique challenges to implementation, whether from public or media responses to preservation techniques or from OPOs that consider some organs to be more costly or of marginal quality.

Presentations

Jimmy A. Light, M.D., of the Washington Hospital Center spoke on a "Legislative Initiative to Preserve the Family Donation Option in the Potential Non-Heart Beating Donor." Dr. Light described the process by which the Washington, DC, city council approved the enactment of a law allowing in situ cannulation of potential donors to maintain the viability of kidneys for four hours to permit families to be contacted, preserving their right to opt for donation. The importance of positive media impressions and effective presentations to stakeholders, including the public, was stressed as vital for the eventual success of any similar legislation in other jurisdictions. The evaluation procedures used by Dr. Light’s team included recording the number of media exposures about the program and administering surveys to people attending informational presentations about their opinion on the procedure, yielding a 90% approval rate. Dr. Light’s team also analyzed donation rates both in cases of cannulation pending consent and in all cases, to determine whether the cannulation policy had an adverse effect on donation. Among the six families of patients undergoing cannulation since the policy was enacted in May 1996, none objected to the procedure, three gave permission to donate, one declined, one could not be reached during the four-hour window of time, and one was lost due to technical failure. Donation rates for the hospital as a whole remained unchanged while the policy was in effect.

Louise M. Jacobbi, Executive Director of the Louisiana Organ Procurement Agency (LOPA), spoke on "Increasing the Number of Transplantable Donor Organs by Expanding Donor Criteria." She described efforts by LOPA to increase the availability of organs by making use of more liberal donor criteria, including a broader age range and accepting as donors patients with hypertension or diabetes. Recognizing benefits and costs inherent in expanded donor protocols, LOPA tracked relative costs of "traditional" and "expanded" donors over the course of the year. The analysis included costs both to the OPO (including hospital costs, personnel time, donors per million population, discard rate, and increase in recovered organs) and to the patient (including patient and graft survival rates and length of stay). Over the study period, 642 organs were transplanted from expanded donors, increasing the number of organs available for the year by 40%. In terms of patient and graft survival, success varied by organ, with expanded hearts performing slightly better than traditional ones, expanded kidneys somewhat worse, and expanded livers significantly worse. The results of the latter two, however, might have been related to the placement of the organs, since some organizations were more inclined to take the risk associated with expanded donors for placement in sicker, more desperate patients. In terms of costs to the OPO, the procurement of the expanded organs incurred an average 17% more in direct hospital costs, 30% more personnel time, and 40% more indirect costs per organ than for traditional organs. These results suggested that expanded donor criteria can be a successful way to increase the number of organs donated, but that careful studies are necessary to understand whether and to what extent such expansion is cost-effective.

Comments
  • Broadly construed to include both direct and indirect costs to the OPO, donor and recipient, the use of cost-benefit analysis and related economic analyses is prevalent in health services research but relatively unexplored in the field of organ donation. The LOPA example is instructive in its attempt to quantify the organizational costs of expanded donors while also evaluating clinical outcomes. Recognizing the importance of economic analyses, the panel recommended collaboration with economists in design and analysis of program evaluations.
  • The panel noted the importance of stakeholder relations to successful organ donation programs. An example was Dr. Light’s mention of the considerable effect on public opinion of media presentations of organ donation procedures, and the need for securing public and policymaker buy-in before pursuing such potentially controversial practices. On an organizational level, the LOPA experience reinforces the need for good communication between OPOs and transplant centers. Clarity about what risk factors a given transplant center will accept in a donor can help to reduce some of the indirect costs incurred by staff trying to place organs unsuccessfully.
  • The expert panel again stressed the need for more complete and extensive data collection and larger sample sizes. In the case of expanded donors in particular, there was a call for more information, including patient and graft survival rates over longer periods of time, data on immunologic compatibility, and the extent to which recipient health status contributes to diminished viability of organs from expanded donors. With larger sample sizes, these factors could be isolated more effectively in a cost model using multivariate analysis.