Increasing Organ Donation and Transplantation: The Challenge of Evaluation. A. Table of Organ Donation Activity Evaluations


Study Overview Evaluation Performance Indicators Stage of Activity Target Findings Comments
Public Awareness
Cosse 1997 Media campaign in US by the Advertising Council, Inc. to educate US public about organ and tissue donation (Phase II July 1995, Phase II October 1995). Time series Pre-event measures: % who expressed a positive attitude towards organ donation;

% who signed donor card

Pre-event activity Community Campaign found an increased percentage of people taking action to sign a donor card after the campaign. The activity described is one step removed from actual organ donation, but was successful in terms of raising awareness. However, the media campaign wasn’t isolated, other activities may have also contributed to this change (e.g., reports about famous recipients like Mickey Mantle and David Crosby).
Schutt 1997 A mailing campaign and public lectures were coordinated through a large medical insurance company; other materials were distributed via affiliated hospitals and the local news media. Time series Rate of organ donation increased by 30% during first 3 months of 1997 compared with same time previous year. Pre-event activity Combined public/ hospital/ primary care provider awareness The rate of organ donation increased in 1997, although PCPs were reluctant to distribute information to patients. Multi-faceted approach with a baseline measurement and follow-up based on actual rate of organ donation. No way to tell which facet of the program had largest impact. No attempt to control for other confounding factors that may have influenced the donation rate.
Persijn 1997 Various public education efforts and the professionalization of an information dissemination office. Time series Pre-event Pre-event Community Increase in different promotional materials disbursed. Very easily collected, but more an illustration of a dissemination office increasing its activity intensity- no post-event or outcome measurements.
Townsend 1990 Discussion groups to educate the African-American community about donation. Time series Pre-event Pre-event Community Increase in donation approval and family discussion after group meeting. Questionnaire easy to collect, but difficult to link activity to organ donation.
Kappel 1993 Two phase effort to increase donation from the African-American community: public education and minority requestor. Time series Post-event Pre-event Community Increase in black referrals, but consent rate remained the same. The disconnect between referral and consent was discussed; data simple to collect; small sample size (5/16 and 4/31).
Callender 1991 Various efforts for African-American community education. Time series Pre-event




Donation rate

Pre-event Community Increase in donor cards signed at DMV over campaign.

Increase in donations over period of campaign.

Good measure of approval/ commitment, easy to collect.



Used only # of donations in 80-89; no rates to adjust for population size or technological advances over a decade; not clear what aspect of a multi-faceted program had the most positive effect.

Wolf 1997 National strategy to promote public acceptance of organ donation. Cross-sectional survey (incomplete) Pre-event Pre-event Community Media penetration strong; positive response in favor of donation for those viewing campaign. Survey fairly easy to collect but must be large; no comparison of change in attitudes of those who hadn’t seen campaign for control.
Gallup 1993 Survey on public attitudes about donation. N/A – survey Pre-event N/A Community National approval of organ donation, etc. Baseline only- might be useful to measure difference over time or by region of intervention.
Stratta 1997 Hypothesis that organ donation rate would increase if the public could be assured that donated organs are appropriately used. N/A Consent rate,

rate of nonrecovery (including donor instability and inability to find recipient), disease/damaged organs, consent rate, utilization

Post-donation Community N/A Not a true evaluation but analyzes steps in the process to identify areas for future activity. Recognition that consent is part of the issue, but hospital needs to improve efforts to use a retrieved organ.
Provider education and hospital/OPO organization
BNA, Feb. 2, 1998 Retrospective survey of donor families and critical care staff concerning perceptions of quality of care and training respectively. Case-control study Post-event measures, but focus on quality of hospital care. Post-event Hospital, donor and nondonor families Donor families ranked the quality of care their loved one received higher than non-donor families. Although this study does not evaluate an activity, the information from this study can be used to identify new interventions to improve quality of care and increase donations.
Chabalewski 1997 A program to promote a greater emphasis on organ donation issues in nursing education programs in the US. Time series Pre-event measures of how many schools incorporate donation & transplantation activities in their curriculum Pre-event Hospital – Nursing schools Nursing schools have become more aware and have started to incorporate more Donation &Transplantation courses and information in their curriculum. Study is an indirect proxy of ultimate organ donation Focus on those directly involved in the organ procurement process post-event, but indirect. Study possibly could be followed up to link education to attitudes and success in clinical practice.
Garrison 1991 Analysis of Kentucky OPO performance over one year. Cohort Post-event Post-event Donors/ families Consent rate higher in cohort for whom requests were decoupled from brain death explanation. Nondeliberate, but good design: presumably randomization of decoupled request though small number of hospitals suggests issues about one or two poor requestors who might have skewed results.
Hartwig 1993 Effect of organ donor race on health team procurement efforts. Cohort Post-event Post-event Hospital African-American patients are less likely to be identified, asked, or become donors. Sample size decent- 85 and 67; use of MRR mitigated potential for skewed results from staff knowing there is interest in studying this issue; MRR involves time and effort.
Niles 1996 Evaluation of the timing factor in the consent process. Cohort Post-event Post-event Donor/ families Decoupled requests more successful. Retrospective study; relatively easy to collect data; OPO-wide sample large enough to be significant.
Cutler 1992 An analysis of donation events in one OPO over two years. Cohort Post-event Post-event Donor/ families OPO coordinators more effective at soliciting consent than physicians. Study doesn’t give numbers of cases, only rates, and says physicians ask most often- if much more often, coordinator success might be less on account of coordinator status than particular success of one good coordinator.
Sheehy 1996 Comparison of procurement success between trauma and non-trauma hospitals. Cohort Donation rate, post-event (No activity) Hospital Trauma centers are more effective at each of the post-event steps and in donation rate. Baseline data only; MRR used is relatively expensive.
Beyer 1992 Study of donations at a Midwest tertiary care hospital over six months. Cohort Post-event Post-event Donor/ families Physician request consent rate higher than when nurse requests; consent rate also higher with higher Death Anxiety Scale (DAS) scores and more liberal religious beliefs (1-6 scale). Regressions performed to calculate results; sample size of 228 requests might be too small to break out so many variables with significance; prospective design stronger than most.
Beasley 1997 Impact of a comprehensive, hospital-focused intervention to increase organ donation over two years at 50 hospitals in three OPOs. Time series Post-event, donation rate Post-event Hospital (from OPO) All measures from ID to donations increased pre-intervention to post-intervention. Large sample lends credibility, as does pre- and post-intervention, rather than during, when there might be a learning curve; data collection largely a part of intervention except MRR, which is relatively onerous.


Cohort Post-event Post-event Hospital (from OPO) Consent rate higher among cohorts for which request was decoupled, made in a quiet/private setting, and OPO coordinator involved. Again, large sample lends credibility, though results might be skewed in that procurement staff might not have followed guidelines for decoupling, etc., even in the midst of an intervention.
Shafer 1997 Impact of inhouse coordinators on organ donation rates in non-donor hospitals, a single coordinator has a contractual obligation to identify and manage potential donors. Time series Donation rate

Post-event measures: Organ donor referrals, donor count, consent rate

Post-event Hospital level, but sponsored by the OPO The program has been a cost-effective way of assisting OPO’s efforts to recover organs from hospitals in Texas. Actual evaluation with outcomes measures, 3-year follow-up. Working directly in the hospital post-event to improve family consent rates, routine notification, and communications with the OPO.
Gentry 1997 Using an "appropriate messenger" (Dr. Callender) approach by hiring an African-American to spearhead a minority community education program and having an on-call African-American coordinator to increase donation rates. Time series Organ donation

Post-Event: Consent Rates

Referral rate

Medically suitable donor referrals

Post-event OPO program initiated at the hospital level Consent rates and donation rates increased among African-American donors. Targeted population in North Texas, focus on increasing minority consent Study design does not control for other potential confounding factors that could have impacted the donation rate beyond the OPO-coordinator program.
Shirley 1994 Assessment of one OPO’s efforts to increase donation by a variety of initiatives. Time series Donation rate, post-event Pre-event, Post-event Hospital (from OPO) Doubling of referrals and donations since beginning of program. Large enough results that program probably works, but the role of each part of a multi-faceted campaign unclear; data easy to collect.
Politoski 1994 Description of continuing education program offered by the National Kidney Foundation. Time series Post-event Pre-event Hospital After the workshop, nurses are more likely to identify donors, initiate requests, and accompany requestor. Relatively easy to collect; translation of pre-event intervention to post-event behavior particularly good (though link to success of these requests would be instructive)- contemporaneous controls might have been useful.
Burris 1996 Effect of a program to define a donation policy, educate staff, and document and monitor compliance at one institution. Time series Donation rate, Post-event Post-event Hospital, Donors/ families After implementation of CQI, significant increases in referrals and donations. Good to measure both donation rate and post-event indicators: sample size for donation rate larger (so more confidence in results), but post-event measures are also significant. Use of request protocol form facilitated data collection.
Kappel 1993 Two phase effort in increase donation from black community: public education and minority requestor. Time series Post-event Post-event Donors/ families Increase in consent rate over time. Good to use post-event measure, but sample size might be too small- researcher doesn’t explain why referrals actually went down over the year of intervention.
GAO 1993 Survey of OPOs on their data collection variables. N/A --Survey Post-event Pre-event OPO What variables OPOs collect, and to what extent. Point: OPOs should collect more, and more consistent, data.
Savaria 1990 Feedback solicited from families of donors. N/A --Survey Pre-event, Post-event Post-event Donor/ families, Community Questions asked about whether donor had donor card or family discussion before precipitating event; also reasons for donating. No comparison with control group of non-donor families; 50% response rate compromises results; sensitive issue; relatively inexpensive.
Shafer 1997 Study of organization of three successful organ procurement organizations. N/A --Survey Outcomes, Post-event, Pre-event, other Both OPO No conclusions drawn, just benchmarks suggested for successful OPOs. Might have relevance with much larger sample sizes that include true cross-section of OPOs (not just three successful ones) to see which variables really do correlate with success.
Morris 1990 Performance of one hospital over 3 years. Single case Post-event Post-event Hospital Baseline data established. Sample size of 10 over 3 years compromises results; MRR to determine potential donors might have been costly.
Kowalski 1996 Assessment of a hospital’s establishment of an Office of Decedent Affairs, whose staff facilitate various aspects of the donation process. Single case Outcome Post-event Hospital After office consolidation, donation rate tripled. Outcome measure suggests success, but unclear which aspect of a multifaceted effort is responsible; easily measured.
McNamara 1997 Medical record review to determine organ procurement effectiveness. Methods Donation rate, Post-event Post-event OPO, Hospital MRR is stronger than death certificate review which is stronger than DPMP as performance measures. Good methodological recommendations.
Evans 1992 Death certificate review to determine organ procurement effectiveness. Methods Donation rate Post-event OPO, Hospital Gives two death certificate review methods to determine potential donor pool. Methodological recommendation; baseline data only.
Wight 1997 Describes the European Donor Hospital Education Programme skills workshop and Donor Action, a program designed to help hospitals improve policies and procedures to optimize donation process with 5 modules: donor detection, referral, family care and communication, maintenance, retrieval. N/A Pre-event measures: Increasing attitude, knowledge, communication, teamwork;

Post-event: increasing approaches to families

Donation rates via MRR

Pre-event activity to help hospitals better handle events Hospital N/A Donor Action program has targeted key weaknesses and identified areas where the most donors were being "lost" -- changes could be measured on a hospital by hospital basis -- this article does not describe any evaluation. MRR and hospital staff surveys are generally expensive to conduct.
Matesanz 1997 Proposal of future activities: proactive donor detection programs with specifically trained professionals, education of the legal profession, social education of health professionals, media, and public opinion, and organizational structure of the organ donation system are all crucial. N/A Ultimately would have to include all three performance indicators Pre-event Range of activities targeting all stakeholders N/A Proposes a wide range of activities but no planned evaluation beyond national organ donation rates and country vs. country comparisons.
Roels 1996 Evaluates presumed consent policies in Austria and Belgium. Cohort Donation rates Pre-event Community DPMP higher in countries with presumed consent policies. Without mention of baseline, not clear that differences don’t correlate with societal differences, but use of two countries eases this issue somewhat- perhaps baseline data could have been included as a historical control; easy to measure.
Bergstrom 1997 Swedish Transplant Coordinators’ experience with the New Transplantation Act and Donor Register which switched presumed non-consent to presumed consent – Government led information campaign, national database of donors and an attitude survey. Time series # of donors, survey of pre-event measures (e.g., donor card signing), and post-event measures (consent rates)


Pre-event Community No difference in number of donors in Sweden had been detected. This study provides one example of how difficult it is to measure changes in the donation rate due to legislation and public awareness activities. The time span of the study may have been too short to detect differences.
Bacque 1997 Development of laws (in Argentina) to ensure transparency and sanitary safety in the development of organ transplantation – Organ Transplant Law 1977 created the National Organ Procurement Organism, shift towards improving provider attitudes and creating a new operational model – Hospital Coordinator Model, and educational campaigns. Retrospective time series DPMP, post-event, and pre-event measures.

Percentage of multiorganic retrieval,

Family refusal rates,

Percent lack of information about brain death and corpse integrity,

Religious refusal,

Percent mistrust

Pre-event Community, hospital providers Found an increase in donation rates and numbers of organs retrieved since legal organization of the organ donation system; Outlines goals for new model as Argentina moves forward. Measures organ donation outcome on a county by county level, measures intermediary predisposition to organ donation. Accounts for effect of government and transplantation model. Age of donors has remained relatively constant.
Nitschke 1997 Comparing legislative periods in Germany with transplantation law and without law but with a centralized system of organ procurement; describes role of the Eurotransplant Foundation to standardize allocation procedures. Time series # of potential organ donors and outcome: effective donors and organs retrieved; refusal rate influenced by the media Pre-event Community The new allocation procedures seem to be successful, despite moving to a system that requires next-of-kin consent. This study measures real outcomes and controls for the death rate but does not control for the fact that the increase in organs may be due to differences in the donor identification rate or other population differences.
Transplant News 1996 Illinois donor card registry. Surveillance Pre-event Pre-event Community % of drivers registered as donors by region used to determine where awareness is lacking. Good use of registry data to focus later program initiatives; could eventually link this data to actual donation rates.
Roels 1997 Presumed consent policy in Belgium. Surveillance Pre-event Pre-event Community Rate of opt-outs determined for natives and foreigners. Baseline only; could use this data to determine change over time, and compare with other countries.
Overcast 1984 Survey of OPOs and state District Attorney offices. N/A --Survey Pre-event (donation rate connection hinted at anecdotally) Pre-event, Post-event Community Most states allow donor designations on licenses; anecdotal information given on % of actual donors who had been donor card carriers; most states don’t have official protocol for police to search for a donor card on an accident scene. Potential to use registries to link actual donors with donor card carriers mentioned, but only anecdotally mentioned.
Rosental 1997 Comparison of informed versus presumed consent law in Baltic States - creation of unified Baltic transplant network. N/A Donations per million population, development of joint policy, adopting legislation, unified waiting list Pre-event Community Rates of transplantation were similar in the Baltic states; the states are now unified by the Balttransplant organization. Not a true evaluation, could be evaluated if comparisons are made at baseline (pre-organization) and at intervals after baseline.