Deceased organ donation consent rates among racial and ethnic minorities and older potential donors

High-Functioning Deceased Donor Kidney Transplant System Characteristics: The British Columbia Experience With an Opt-In System

Rationale & Objective

A high level of cooperation between organ procurement organizations and transplant programs may help maximize use of deceased donor kidneys. The practices that are essential for a high functioning organ donation and transplant system remain uncertain. We sought to report metrics of organ donation and transplant performance in British Columbia, Canada, and to assess the association of specific policies and practices that contribute to the system's performance.

Study Design

A retrospective observational study.

Setting & Participants

Referred deceased organ donors in British Columbia were used in the study from January 1, 2016, to December 31 2019.

Exposures

Provincial, organ procurement organization, and center level policies were implemented to improve donor referral and organ utilization.

Outcomes

Assessment of donor and kidney utilization along steps of the critical pathway for organ donation.

Analytical Approach

Deceased donors were classified according to the critical pathway for organ donation and key donation and transplant metrics were identified.

Results

There were 1,948 possible donors referred. Of 1,948, 754 (39%) were potential donors. Of 754 potential donors, 587 (78%) were consented donors. Of 587 consented donors, 480 (82%) were eligible kidney donors. Of 480 eligible kidney donors, 438 (91%) were actual kidney donors. And of 438 actual kidney donors, 432 (99%) were utilized kidney donors. One-year all-cause allograft survival was 95%. Practices implemented to improve the system's performance included hospital donor coordinators, early communication between the organ procurement organization and transplant nephrologists, dedicated organ recovery and implant surgeons, aged-based kidney allocation, and hospital admission of recipients before kidney recovery.

Limitations

Assignment of causality between individual policies and practices and organ donation and utilization is limited in this observational study.

Conclusions

In British Columbia, consent for donation, utilization of donated kidneys, and transplant survival are exceptionally high, suggesting the importance of an integrated deceased donor and kidney transplant service.

Proposal and Rationale for a Cardioethics Curriculum

The modern practice of cardiovascular medicine involves many ethical controversies in the care of our complex patients. Accordingly, we propose a framework for a practical, clinically based "cardioethics" curriculum that might be incorporated into fellowship training to prepare cardiologists to cope with increasingly complex ethical dilemmas. This work can also be adopted into continuing medical education for cardiologists and other cardiovascular practitioners given the critical importance of collaborative care in cardiology. We discuss heart transplant allocation, futility concerns, withdrawing care, advance care planning, conflicts of interests, and distributive justice. Sound ethical decision-making in cardiology requires a combination of extensive technical knowledge, nuanced appreciation of individual patient goals and values, and thoughtful application of ethical principles and reasoning. Cardiologists have an exceptionally broad toolkit of medications and interventions to address high-stakes disease states. We should maintain a similarly broad ethical toolkit to provide the best care for our patients.

Impact of demographic factors on corneal donor recovery

PURPOSE

Death-to-preservation time (DTP) is a commonly reported, but infrequently studied, measure of efficiency for the corneal tissue procurement process and is a key screening component for corneal tissue suitability for transplantation. It is unknown whether demographic factors such as race, age, or gender may affect DTP.

METHODS

This retrospective cross-sectional study included all deceased-donor eye tissue collected by CorneaGen Eye Banks between June 1, 2012 and June 30, 2016. Exposure variables of race, age, and gender were independently analyzed with the outcome variable, DTP, using three simple linear regression analyzes. Associations were then confirmed by a multiple linear regression analysis within a single model.

RESULTS

A total of 24,138 unique donors were identified from 48,207 donor eyes. Simple linear regression analysis showed that relative to White donors, Black and Hispanic donors were associated with a 2.40 h (95% CI 2.07-2.74 h, p < 0.001) and 2.48 h (95% CI 2.15-2.80 h, p < 0.001) longer mean DTP, respectively. DTP decreased with increasing age, at a rate of 30 min per every 10 years (95% CI 27-33 min, p < 0.001). Male donors were associated with a 35 min (95% CI 26-44 min, p < 0.001) longer DTP relative to female donors. A multiple linear regression confirmed the results of the three simple linear regressions.

CONCLUSIONS

In a large cohort of corneal donors, non-White race, younger age, and male gender were associated with longer DTP.

Racial disparities across multiple stages of the deceased organ donation process

Pervasive structural violence causes higher organ failure rates among Black Americans and excess Black potential deceased organ donors. Underuse of Black donors would exacerbate organ shortages that disproportionately harm Black transplant candidates. This study investigates racial differences in transit between distinct donation steps among 132 968 potential donors across 557 hospitals and 6 Organ Procurement Organizations (OPOs) from 2015 through 2021. Multilevel multistate modeling with patient covariates and OPO random effects shows adjusted likelihoods (95% confidence interval [CI]) of non-Black versus Black patients transitioning from OPO referral to approach: odds ratio (OR) 1.23 (95% CI 1.18, 1.27), approach to authorization: OR 1.64 (95% CI 1.56, 1.72), authorization to procurement: OR 1.08 (95% CI 1.02, 1.14), and procurement to transplant: OR 0.99 (95% CI 0.93, 1.04). Overall organ utilization rates for Black, Latino, White, and other OPO referrals were 5.88%, 8.17%, 6.78%, and 5.24%, respectively. Adjusting for patient covariates and hospital and OPO random effects, multilevel logistic models estimated that compared with Black patients, Latino, White, and other patients had ORs of organ utilization of 1.82 (95% CI 1.61, 2.04), 3.19 (95% CI 2.91, 3.50), and 1.25 (95% CI 1.06, 1.47), respectively. Nationwide in 2022, donor conversion disparities likely lost more than 1800 donors-70% of whom would have been Black. Achieving racial equity for transplant candidates will require reducing racial disparities in organ donation.

The Impact of Ethnicity on Research Authorization at the Time of Organ Donation: A Single-Center Experience Among Deceased Donor Kidney Transplantation

Objective

Research on deceased organ donors is needed to expand the donor organ supply. Little is known about the rate of research authorization among various groups. We aimed to determine the percentage of research authorization by the deceased donor family across different donor characteristics.

Materials and Methods

We performed a retrospective review of deceased donors referred to one U.S. institution for kidney transplantation over a 12-month period. Organs were offered from multiple organ procurement organizations (OPO) across the United States. Stepwise logistic regression was performed to determine the predictors of research authorization.

Results

From 10/2018 to 10/2019, 437 deceased donors were accepted for transplantation. 81.5% came from OPOs outside our donor service area and 18.5% from our local OPO. Overall, research authorization was declined in 24.0% of donors. Declined authorization was highest among Black donors (42.0%) compared to Whites (16.3%) and Hispanics (26.9%); p=0.000006. Donors <35 years had highest declined research authorization at 42.9% compared to older donors. There were no significant differences between individual OPOs.

Conclusion

Deceased donor research authorization declined at the time of organ donation is higher among Black and younger donors. There is an immediate need for the transplant and donor community to develop best-practices to eliminate barriers to research in organ transplantation.

Taking a "Care Pathway/Whole Systems" Approach to Equality Diversity Inclusion (EDI) in Organ Donation and Transplantation in Relation to the Needs of "Ethnic/Racial/Migrant" Minority Communities: A Statement and a Call for Action

International evidence shows variation in organ donation and transplantation (ODT) based upon a range of patient characteristics. What is less well understood is the impact of patient "ethnicity/race/immigration background," as these terms are defined and intended differently across countries. We also know that these characteristics do not operate in isolation but intersect with a range of factors. In this paper, we propose a framework that seeks to clarify the definition of the key terms "ethnicity/race/migrant" and to review how these communities are operationalized across European studies about inequities in ODT. Further, patients and the public wish to see Equality Diversity Inclusion (EDI) approaches in their everyday lives, not just in relation to ODT. We propose a 'care pathway/whole-systems' approach to ODT encompassing culturally competent public health interventions for a) the prevention and management of chronic diseases, b) improvements in public engagement for the promotion of the culture of ODT and enhancements in end-of-life care, through to c) enhanced likelihood of successful transplant among migrant/ethnic minority communities. Our framework recognizes that if we truly wish to take an EDI approach to ODT, we need to adopt a more social, human and holistic approach to examining questions around patient ethnicity.

Organ Donation Willingness Among Asian Americans: Results from a National Study

Asian Americans are the fastest growing racial group in the USA, but their health disparities are often overlooked. Although their needs for transplantable organs are substantial, they have the lowest rates of organ donation per million compared to other Americans by race. To better understand Asian Americans' disposition toward organ donation, a self-administered survey was developed based on formative data collection and guidance from a Community Advisory Board composed of Asian American stakeholders. The instrument was deployed online, and quota sampling based on the 2017 American Community Survey was used to achieve a sample representative (N = 899) of the Asian American population. Bivariate tests using logistic regression and the chi-square test of independence were performed. Over half (58.1%) of respondents were willing to be organ donors. A majority (81.8%) expressed a willingness to donate a family member's organs, but enthusiasm depended on the family member's donor wishes. Only 9.5% of respondents indicated that the decision to donate their organs was theirs alone to make; the remainder would involve at least one other family member. Other key sociodemographic associations were found. This study demonstrates both the diversity of Asian Americans but also the centrality of the family's role in making decisions about organ donation. Practice and research considerations for the field are also presented.

Organ Transplantation Outcomes of Deceased Organ Donors in Organ Procurement Organization-Based Recovery Facilities Versus Acute-Care Hospitals

INTRODUCTION

Recovery of donated organs at organ procurement organization (OPO)-based recovery facilities has been proposed to improve organ donation outcomes, but few data exist to characterize differences between facilities and acute-care hospitals.

RESEARCH QUESTION

To compare donation outcomes between organ donors that underwent recovery procedures in OPO-based recovery facilities and hospitals.

DESIGN

Retrospective study of Organ Procurement and Transplantation Network data. From a population-based sample of deceased donors after brain death April 2017 to June 2021, donation outcomes were examined in 10 OPO regions with organ recovery facilities. Primary exposure was organ recovery procedure in an OPO-based organ recovery. Primary outcome was the number of organs transplanted per donor. Multivariable regression models were used to adjust for donor characteristics and managing OPO.

RESULTS

Among 5010 cohort donors, 2590 (51.7%) underwent recovery procedures in an OPO-based facility. Donors in facilities differed from those in hospitals, including recovery year, mechanisms of death, and some comorbid diseases. Donors in OPO-based facilities had higher total numbers of organs transplanted per donor (mean 3.5 [SD1.8] vs 3.3 [SD1.8]; adjusted mean difference 0.27, 95% confidence interval 0.18-0.36). Organ recovery at an OPO-based facility was also associated with more lungs, livers, and pancreases transplanted.

CONCLUSION

Organ recovery procedures at OPO-based facilities were associated with more organs transplanted per donor than in hospitals. Increasing access to OPO-based organ recovery facilities may improve rates of organ transplantation from deceased organ donors, although further data are needed on other important donor management quality metrics.

Surgical Science and the Evolution of Critical Care Medicine

Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.

A mixed-methods examination of public attitudes toward vascularized composite allograft donation and transplantation

Background:

This mixed-methods study examined the general public’s knowledge and attitudes about vascularized composite allografts. The availability of these anatomical gifts to treat individuals with severe disfiguring injuries relies largely on decisions made by family members. If vascularized composite allograft transplantation is to become more readily available, the knowledge and beliefs of the general public must be explored to ensure vascularized composite allograft donation approaches adequately support the donation decision-making process.

Methods:

We conducted six focus groups with 53 members of the general public, which were audio-recorded for accuracy and transcribed. Before each session, participants completed a brief survey assessing donation-related knowledge, attitudes, and beliefs. Analysis of qualitative data entailed the constant comparison method in the development and application of a schema for thematic coding. Descriptive statistics and Spearman’s rank coefficient were used in the analysis of the quantitative data.

Results:

Respondents were most knowledgeable about solid organ donation and least knowledgeable about vascularized composite allograft donation. Six major themes emerged: (1) strong initial reactions toward vascularized composite allografts, (2) limited knowledge of and reservations about vascularized composite allografts, (3) risk versus reward in receiving a vascularized composite allograft, (4) information needed to authorize vascularized composite allograft donation, (5) attitudes toward donation, and (6) mistrust of the organ donation system.

Conclusion:

The general public has low levels of knowledge and high levels of hesitation about vascularized composite allograft donation and transplantation. Education campaigns to familiarize the general public with vascularized composite allografts and specialized training for donation professionals to support informed family decision-making about vascularized composite allograft donation may address these issues.

Disparities in Lung Transplantation

Since the initial report of long-term survival after lung transplantation (LT) in 1983, there has been remarkable progress in the field and LT is now the gold-standard therapy for patients with end-stage lung disease. It confers a significant survival advantage and improves the quality of life in patients who often have few other treatment options. However, LT remains a complex undertaking and establishing and maintaining an LT program is resource intensive with multiple potential barriers. In this article, we focus on disparities in LT and the potential solutions to improving access to LT.

Disparities in Deceased Organ Donor Research Authorization: Experience at One Organ Procurement Organization and Call for National Conversations

Introduction

Research with deceased donor organs can provide an important platform for studying interventions to improve organ use and outcomes after authorization from the next-of-kin (NOK) or before death by the decedent (i.e., first-person authorization [FPA]). To date, information on authorization rates across donor subgroups is lacking.

Methods

We performed a retrospective chart review of all 690 deceased organ donors from January 2017 to December 2019 at a midsized Midwestern organ procurement organization (OPO). Multivariable logistic regression was used to assess associations between donor factors and research decline (adjusted odds ratio [aOR], 95% confidence interval [CI]).

Results

Electronic records for all 690 deceased donors were reviewed. Of these, 659 (95.5%) yielded at least one transplanted organ. Overall, research was declined in 10.8% of donations. Compared to White donors, research decline was higher for Black (16.0% vs. 8.9%; aOR, 1.87; 95% CI, 1.03-3.40; P = 0.04) and other non-White donors (24.0% vs. 8.9%; aOR, 4.21; 95% CI, 1.02-17.39; P = 0.05). Unadjusted research decline trended higher for Hispanic donors versus non-Hispanic donors (23.1% vs. 10.5%; P = 0.14). Compared to donors age <40 years, research decline trended higher for donors age ≥65 years (16.7% vs. 11.8%; aOR, 4.87; 95% CI, 1.12-21.05; P = 0.03), whereas research decline was 55% lower when donors provided FPA (7.3% vs 15.0%; aOR, 0.45; 95% CI, 0.27-0.76; P = 0.003).

Conclusions

Deceased donor research authorization decline is higher for Black, other non-White, and older donors, but lower when the descendent provides FPA. Identification of disparities in research authorization may stimulate educational strategies to reduce barriers to scientific investigations directed at optimizing the outcomes of organ donation.

Reexamining Risk Aversion: Willingness to Pursue and Utilize Nonideal Donor Livers Among US Donation Service Areas

Background

Livers from "nonideal" but acceptable donors are underutilized; however, organ procurement organization (OPO) metrics do not assess how OPO-specific practices contribute to these trends. In this analysis, we evaluated nonideal liver donor avoidance or risk aversion among OPOs and within US donation service areas (DSAs).

Methods

Adult donors in the United Network for Organ Sharing registry who donated ≥1 organ for transplantation between 2007 and 2019 were included. Nonideal donors were defined by any of the following: age > 70, hepatitis C seropositive, body mass index > 40, donation after circulatory death, or history of malignancy. OPO-specific performance was evaluated based on rates of nonideal donor pursuit and consent attainment. DSA performance (OPO + transplant centers) was evaluated based on rates of nonideal donor pursuit, consent attainment, liver recovery, and transplantation. Lower rates were considered to represent increased donor avoidance or increased risk aversion.

Results

Of 97 911 donors, 31 799 (32.5%) were nonideal. Unadjusted OPO-level rates of nonideal donor pursuit ranged from 88% to 100%. In a 5-tier system of overall risk aversion, tier 5 DSAs (least risk-averse) and tier 1 DSAs (most risk-averse) had the highest and lowest respective rates of non-ideal donor pursuit, consent attainment, liver recovery, and transplantation. On average, recovery rates were over 25% higher among tier 5 versus tier 1 DSAs. If tier 1 DSAs had achieved the same average liver recovery rate as tier 5 DSAs, approximately 2100 additional livers could have been recovered during the study period.

Conclusion

Most OPOs aggressively pursue nonideal liver donors; however, recovery practices vary widely among DSAs. Fair OPO evaluations should consider early donation process stages to best disentangle OPO and center-level practices.

Comparison of pediatric brain-dead donors to donation after circulatory death donors in the United States

In pediatrics, an increasing need for transplantable organs exists. This study aimed to describe the epidemiology of pediatric deceased donors in the United States. This retrospective observational study utilized data from the Organ Procurement and Transplantation Network (OPTN) from 2000 to 2015. Patients were stratified based on method of organ donation. Demographic variables and mechanism of death were then compared. A total of 14,481 deceased pediatric organ donors, donation after brain death (DBD) and donation after circulatory death (DCD), were included in the study, of which 8% were DCD donors. A significant difference (p<0.001) existed between the two donor groups with respect to ethnicity and mechanism of death. The annual trend of DCD and DBD donors showed an inverse relationship. During the 15-year study period the number of DBD donors decreased from 985 to 785 per year while DCD donors increased from 15 to 146 per year. As well, overall organs transplanted per year decreased from 3,475 to 3,117 over the 15-year study period. Significant differences exist between pediatric DBD donors and DCD donors, specifically with respect to ethnicity and mechanism of death. The number of pediatric DBD donors is decreasing while the number of pediatric DCD is slowly rising, making it increasingly important to be able to characterize these donors to better identify eligible DCD donors to optimize organ utilization.

Examination of Racial and Ethnic Differences in Deceased Organ Donation Ratio Over Time in the US

Importance

Historically, deceased organ donation was lower among Black compared with White populations, motivating efforts to reduce racial disparities. The overarching effect of these efforts in Black and other racial/ethnic groups remains unclear.

Objective

To examine changes in deceased organ donation over time.

Design, Setting, and Participants

This population-based cohort study used data from January 1, 1999, through December 31, 2017, from the Scientific Registry of Transplant Recipients to quantify the number of actual deceased organ donors, and from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research Detailed Mortality File to quantify the number of potential donors (individuals who died under conditions consistent with organ donation). Data were analyzed from December 2, 2019, to May 14, 2020.

Exposures

Race and ethnicity of deceased and potential donors.

Main Outcomes and Measures

For each racial/ethnic group and year, a donation ratio was calculated as the number of actual deceased donors divided by the number of potential donors. Direct age and sex standardization was used to allow for group comparisons, and Poisson regression was used to quantify changes in donation ratio over time.

Results

A total of 141 534 deceased donors and 5 268 200 potential donors were included in the analysis. Among Black individuals, the donation ratio increased 2.58-fold from 1999 to 2017 (yearly change in adjusted incidence rate ratio [aIRR], 1.05; 95% CI, 1.05-1.05; P < .001). This increase was significantly greater than the 1.60-fold increase seen in White individuals. Nevertheless, substantial racial differences remained, with Black individuals still donating at only 69% the rate of White individuals in 2017 (P < .001). Among other racial minority populations, changes were less drastic. Deceased organ donation increased 1.80-fold among American Indian/Alaska Native and 1.40-fold among Asian or Pacific Islander populations, with substantial racial differences remaining in 2017 (American Indian/Alaska Native population donation at 28% and Asian/Pacific Islander population donation at 85% the rate of the White population). Deceased organ donation differences between Hispanic/Latino and non-Hispanic/Latino populations increased over time (4% lower in 2017).

Conclusions and Relevance

The findings of this cohort study suggest that differences in deceased organ donation between White and some racial minority populations have attenuated over time. The greatest gains were observed among Black individuals, who have been the primary targets of study and intervention. Despite improvements, substantial differences remain, suggesting that novel approaches are needed to understand and address relatively lower rates of deceased organ donation among all racial minorities.

A three-tier system for evaluation of organ procurement organizations' willingness to pursue and utilize nonideal donor lungs

Lungs from "nonideal," but acceptable donors are underutilized; however, organ procurement organization (OPO) metrics do not reflect the extent to which OPO-specific practices contribute to these trends. We developed a comprehensive system to evaluate nonideal lung donor avoidance, or risk aversion among OPOs. Adult donors in the UNOS registry who donated ≥1 organ for transplantation between 2007 and 2018 were included. Nonideal donors had any of age>50, smoking history ≥20 pack-years, PaO₂ /FiO₂ ratio ≤350, donation after circulatory death, or increased risk status. OPO-level risk aversion in donor pursuit, consent attainment, lung recovery, and transplantation was assessed. Among 83916 donors, 70372 (83.9%) were nonideal. Unadjusted OPO-level rates of nonideal donor pursuit ranged from 81 to 100%. In a three-tier system of overall risk aversion, tier 3 OPOs (least risk-averse) had the highest rates of nonideal donor pursuit, consent attainment, lung recovery, and transplantation. Tier 1 OPOs (most risk-averse) had the lowest rates of donor pursuit, consent attainment, and lung recovery, but higher rates of transplantation compared to tier 2 OPOs (moderately risk-averse). Risk aversion varies among OPOs and across the donation process. OPO evaluations should reflect early donation process stages to best differentiate over- and underperforming OPOs and encourage optimal OPO-specific performance.

Organ Donation Authorization After Brain Death Among Patients Admitted to PICUs in the United States, 2009-2018

OBJECTIVES

To identify trends in and factors associated with pediatric organ donation authorization after brain death.

DESIGN

Retrospective cohort study of data from Virtual Pediatric Systems, LLC (Los Angeles, CA).

SETTING

Data from 123 PICUs reporting to Virtual Pediatric Systems from 2009 to 2018.

PATIENTS

Patients less than 19 years old eligible for organ donation after brain death.

MEASUREMENTS AND MAIN RESULTS

Of 2,777 eligible patients, 1,935 (70%) were authorized for organ donation; the authorization rate remained unchanged over time (ptrend = 0.22). In a multivariable logistic regression model, hospitalizations lasting greater than 7 days had lower odds of authorization (adjusted odds ratio, 0.5; p < 0.001 vs ≤ 1 d) and White patients had higher odds than other race/ethnicity groups. Authorization was higher for trauma-related encounters (adjusted odds ratio, 1.5; p < 0.001) and when donation was discussed with an organ procurement organization coordinator (adjusted odds ratio, 1.7; p < 0.001). Of 123 hospitals, 35 (28%) met or exceeded a 75% organ donation authorization target threshold; these hospitals more often had an organ procurement organization coordinator discussing organ donation (85% vs 72% of encounters; p < 0.001), but no difference was observed by PICU bed size.

CONCLUSIONS

Organ donation authorization after brain death among PICU patients was associated with length of stay, race/ethnicity, and trauma-related encounter, and authorization rates were higher when an organ procurement organization coordinator was involved in the donation discussion. This study identified factors that could inform initiatives to improve the authorization process and increase pediatric organ donation rates.

Neighborhood socioeconomic deprivation, racial segregation, and organ donation across 5 states

One in 10 people die awaiting transplantation from donor shortage. Only half of Americans register as organ donors. In this cross-sectional study, we evaluated population-level associations of neighborhood socioeconomic deprivation and racial segregation on organ donor registration rates. We analyzed state identification card demographic and organ donor registration data from 5 states to estimate the association between a neighborhood socioeconomic deprivation index (range [0, 1]; higher values indicate more deprivation) and a racial index of concentration at the extreme (ICE) (range [-1, 1]; lower values indicate predominantly black neighborhoods, higher values indicate predominantly white neighborhoods) on organ donor registration rates within a specified geography (census tract or ZIP code tabulation area [ZCTA]). Among 26 720 738 registrants, 32% of the sample were registered organ donors. At the census tract level, with each 0.1 decrease in the deprivation index, the organ donor registration rate increased by 6.8% (95% confidence interval [CI]: 6.6%, 7.0%). With each 0.1 increase in the racial ICE, the rate increased by 1.5% (95% CI: 1.5%, 1.6%). These associations held true at the ZCTA level. Areas with less socioeconomic deprivation and a higher concentration of white residents have higher organ donor registration rates. Public health initiatives should consider neighborhood context and novel data sources in designing optimal intervention strategies.

Survey of public attitudes towards imminent death donation in the United States

Imminent death donation (IDD) is described as living organ donation prior to a planned withdrawal of life-sustaining care in an imminently dying patient. Although IDD was ethically justified by United Network for Organ Sharing, the concept remains controversial due to presumed lack of public support. The aim of this study was to evaluate the public's attitudes towards IDD. A cross-sectional survey was conducted of US adults age >18 years (n = 2644). The survey included a case scenario of a patient with a devastating brain injury. Responses were assessed on a 5-point Likert scale. Results showed that 68% - 74% of participants agreed or strongly agreed with IDD when posed as a general question and in relation to the case scenario. Participants were concerned about "recovery after a devastating brain injury" (34%), and that "doctors would not try as hard to save a patient's life" (33%). Only 9% of participants would be less likely to trust the organ donation process. In conclusion, our study demonstrates strong public support for IDD in the case of a patient with a devastating brain injury. Notably, participants were not largely concerned with losing trust in the organ donation process. These results justify policy change towards imminent death donation.

A Randomized Trial of Theory-Informed Appeals for Organ Donor Registration Using Internet Advertisements

Introduction

Many people do not register as organ donors. We developed 5 different brief appeals for organ donation that were disseminated online. The content was informed by theories of behavior change and studies of the specific cognitive barriers to organ donor registration.

Methods

One message was a persuasive narrative about a transplant recipient. Another message promoted the idea that organ donor registration is a social norm. The knowledge-based message communicated that 1 donor could improve the lives of 50 people. The message on reciprocity offered a free organ donation wristband, whether or not the participant registered as a donor. The message on control simply encouraged organ donation. Using Google AdWords, the messages were deployed randomly as banners of different sizes on diverse online sites and carried a link to an organ donor registration site. We measured clicks, page visits, and organ donor registrations.

Results

There were 5,156,048 impressions and 25,001 total clicks, a click-through rate of 0.49%. The messages on control and reciprocity both had the highest click-through rates of 0.51%. A total of 152 unique individuals requested wristbands and there were 52 total organ donor registration events. The message on reciprocity had the highest number of organ donor registrations (n = 18).

Conclusion

Online organ donation messages rapidly generated substantial attention through clicks, but no message led to a meaningful number of organ donor registrations. Future research may focus on effectively capturing the attention of viewers through social networks or other convenient online venues with less competition for attention than Internet banners.

Seeking consent for organ donation: Process evaluation of implementing a new Specialist Requester nursing role

AIM

To explain the differences in organ donation consent outcomes of a new nursing role (Specialist Requesters) derived from the United States (US) compared with the existing nursing role (Specialist Nurses in Organ Donation).

DESIGN

Thirty-month observational qualitative process evaluation: Implementation theory-informed analysis.

METHODS

Qualitative content analysis of free text describing challenges, processes and practice from 996 bespoke routinely collected potential organ donor 'approach forms' from two regions: one where there was no difference, and one with an observed difference in consent outcomes.

RESULTS

Region A consent rate: Specialist Requester 75.8%, Specialist Nurse in Organ Donation71.8%. Region B consent rate: Specialist Requester 71.4%, Specialist Nurse in Organ Donation 82%. Region A Specialist Requesters turned the family position from no or uncertain to support organ donation in 73% of cases, compared with 27.4% in Region B. Two Specialist Requesters in Region A were highly effective. Region B experienced problems with intervention fidelity and implementation.

CONCLUSIONS

The benefits of the Specialist Requester role remain unclear. Positive differences in consent rates achieved by Specialist Requesters in the originator region reduced over time and have yet to be successfully replicated in other regions.

IMPACT

The impact of Specialist Requesters on consent outcomes varied across regions and it was not known why. Specialist Requesters in Region A were better at getting family member(s) to support organ donation. In Region B, Specialist Nurse in Organ Donation consent rates were higher and problems with intervention fidelity were identified (recruitment, staffing, less experience). Policy makers need to understand it is not just a matter of waiting for the Specialist Requester intervention to work. Ongoing training and recruiting the right people with the right skills need to be addressed and consistently reviewed.

Estimating the effect of focused donor registration efforts on the number of organ donors

Waiting times for organs in the United States are long and vary widely across regions. Donor registration can increase the number of potential donors, but its effect on the actual number of organ transplants depends upon several factors. First among these factors is that deceased donor organ donation requires both that death occur in a way making recovery possible and that authorization to recover organs is obtained. We estimate the potential donor death rate and donor authorization rate conditional on potential donor death by donor registration status for each state and for key demographic groups. With this information, we then develop a simple measure of the value of a new donor registration. This combined measure using information on donor authorization rates and potential death rates varies widely across states and groups, suggesting that focusing registration efforts on high-value groups and locations can significantly increase the overall number of donors. Targeting high-value states raises 26.7 percent more donors than a uniform, nationwide registration effort. Our estimates can also be used to assess alternative, but complementary, policies such as protocols to improve authorization rates for non-registered potential donors.

Click it or give it: Increased seat belt law enforcement and organ donation

Laws mandating that individuals wear a seat belt have the presumed goal of reducing motor vehicle accident fatalities, but the prevailing view is that they may reduce the number of organs available. I provide a conceptual model identifying mechanisms whereby the law could either increase or decrease organ donation. Exploiting variation across states and time in the adoption of primary seat belt enforcement, I investigate these mechanisms and estimate the effect of the law on the supply of organs. The law increases seat belt usage and decreases motor vehicle accident fatalities, which translates to a sizeable reduction in the number of motor vehicle accident-based organ donors. In contrast, the law is not associated with changes in the number of organ donors from nonmotor vehicle accident-based sources and is robust to controlling for hospital-specific effects. The effects are concentrated within organs expected to be most negatively impacted by the seat belt. Although primary enforcement represents a net-gain to society in terms of lives saved, the negative impact on organ donation suggests further emphasis be placed on policies aimed at increasing the availability of organs.

Organ donation in the US and Europe: The supply vs demand imbalance

Organ donation and transplantation remain the best and most cost-effective clinical solution for end-stage organ failure. Several agencies across the US and Europe provide legislative, regulatory, and humanitarian services to generate smoother applications in all transplantation processes and donor-recipient relationships. US and European statistics present nine types of grafts, with kidneys being the most transplanted organ worldwide. However, organ shortage, religion, underrepresented minority groups, difficulties in obtaining consent, lack of understanding, and general ethical concerns present challenging barriers to organ donation, reflecting the complexity of graft procurement and allocation. Breaking down these barriers to reduce the organ-supply imbalance requires an appropriate multifaceted approach. Some of the key areas include increasing the potential donor pool and consent rates, apt organ allocation, and improving organ health. Additionally, suitable policies and standardized guidelines for both donors and recipients, alongside educational initiatives, are needed to ensure patient safety and global awareness. Looking forward, novel and effective research plans and initiatives are needed if we are to avoid a colossal supply-demand gap.

Rejecting bias: The case against race adjustment for OPO performance in communities of color

In December of 2019, the Centers for Medicare and Medicaid Services (CMS) put out a notice of proposed rule-making for 42 CFR Part 486, specifically the section that covers the organ procurement organization (OPO) Conditions for Coverage. Most crucially, the proposed rule included two new OPO performance metrics using objective, standardized data from the Centers for Disease Control and Prevention (CDC). These new metrics would employ a denominator that included inpatient deaths from certain causes that could lead to organ donation, rather than the current unverifiable eligible death metric. Although there has been near-uniform support for replacing the eligible death denominator with CDC data, a source of contention is CMS's proposal not to adjust risk for race in their OPO outcome. Nonetheless, there have been calls for race and ethnicity to be included as risk-adjusted variables in the CMS donation metric. Herein, we lay out an argument as to why inclusion of race and ethnicity as risk adjustment variables in an OPO performance metric is not only statistically suspect but also will hide the inequities that are detrimental to optimal system performance and assurance that all patients have timely access to donation.

Wide Variation in the Percentage of Donation After Circulatory Death Donors Across Donor Service Areas: A Potential Target for Improvement

BACKGROUND

Substantial differences exist in the clinical characteristics of donors across the 58 donor service areas (DSAs). Organ procurement organization (OPO) performance metrics incorporate organs donated after circulatory determination of death (DCDD) donors but do not measure potential DCDD donors.

METHODS

Using 2011-2016 United Network for Organ Sharing data, we examined the variability in DCDD donors/all deceased donors (%DCDD) across DSAs. We supplemented United Network for Organ Sharing data with CDC death records and OPO statistics to characterize underlying process and system factors that may correlate with donors and utilization.

RESULTS

Among 52 184 deceased donors, the %DCDD varied widely across DSAs, with a median of 15.1% (interquartile range [9.3%, 20.9%]; range 0.0%-32.0%). The %DCDD had a modest positive correlation with 4 DSA factors: median match model for end-stage liver disease, proportion of white deaths out of total deaths, kidney center competition, and %DCDD livers by a local transplant center (all Spearman coefficients 0.289-0.464), and negative correlation with 1 factor: mean kidney waiting time (Spearman coefficient -0.388). Adjusting for correlated variables in linear regression explained 46.3% of the variability in %DCDD.

CONCLUSIONS

Donor pool demographics, waitlist metrics, center competition, and DCDD utilization explain only a portion of the variability of DCDD donors. This requires further studies and policy changes to encourage consideration of all possible organ donors.

A Comparison of the Content and Quality of Organ Donation Discussions with African American Families Who Authorize and Refuse Donation

BACKGROUND

This study compares the experiences of African American (AA) families who authorized organ donation with those who refused.

METHODS

Large administrative datasets were obtained from 9 partnering Organ Procurement Organizations (OPO). Initial analyses used these data to assess authorization among African American families (n = 1651). Subsequent analyses were performed using a subsample of interview data of AA family decision makers (n = 276). Initial bivariate analyses tested differences in study variables by authorization status (donor/nondonor). Two separate multilevel logistic regressions examined associations between independent variables and family authorization.

RESULTS

Analyses of the administrative datasets found that refusal was more likely when the patient was older, female, a DCD case, and not referred in a timely manner; refusal was less likely when families initiated donation conversations. Interview data revealed that families who refused donation were less likely to respond favorably to initial donation requests and reported less satisfaction with the overall approach, amount of time with OPO staff, and how questions were handled. Refusing families were also more likely to feel pressured, had less comprehensive donation discussions, and rated the OPO requesters' communication skills lower. No significant differences in organ donation attitudes were found between families who authorized donation and those refusing to donate.

CONCLUSIONS

The study suggests that AA families making decisions about organ donation would benefit from culturally appropriate discussions.

TRIAL REGISTRATION

Clinical Trial Notation: NCT02138227.

Informed Clustering of Donation Service Areas for Improved Benchmarking

The donation community continuously strives to collaborate and share effective practices to further the mission of saving and healing lives. Donation service areas in which the Organ Procurement Organizations (OPOs) work are multifaceted in their demographics, inciting the Organ Procurement and Transplantation Network to consider a more holistic and objective measure of similarity rather than the size of population alone or locational proximity alone. This would allow OPOs, as a part of their quality improvement efforts, to learn from and mentor other organizations that are dealing with similar challenges. By incorporating multiple informative characteristics together, we can distinguish those likenesses only revealed by taking into account multiple factors simultaneously. We used statistical approaches that take many characteristics of interest describing a donation service area and purposely excluded performance measures that an OPO may be able to influence by their own practices. Unsupervised learning methods combined the original characteristics into a smaller number of new variables, eliminating correlation and overlap in information from the original characteristics, and clustered donation service areas based on the general characteristics and population of the area. This analysis is a first step in providing a different perspective for OPOs to learn from other organizations that may face similar challenges, as well as to share best practices and open new lines of communication.

Predictors of Older Donor Lung Use: Are We Too Good at Saying No?

BACKGROUND

Patterns of use of older donor lungs within this previously underused donor population are poorly characterized. This study examined factors associated with the use of older donor lung allografts and factors associated with survival in recipients of these lungs.

METHODS

Adult donors in the United Network for Organ Sharing registry who donated 1 or more organs for transplantation between 2006 and 2018 were analyzed and stratified into older (age >55 years) and younger (age ≤55 years) cohorts. Multivariable logistic and Cox regression were used to identify factors associated with transplantation of older donor lungs and factors associated with survival, respectively.

RESULTS

Overall, 202,477 donors were included and stratified by age (older, 40,406 [20%]; younger, 162,071 [80%]). Compared with younger donors, older donors had an increased rate of consent for donation not requested by organ procurement organizations (7.5% vs 1.7%). Donor factors significantly associated with decreased lung use included male sex, increasing donor age, black race, Hispanic ethnicity, cigarette use, cocaine use, donation after circulatory death status, and PaO₂/FiO₂ (P/F ratio) lower than 350. In recipients of older donor lungs, increasing donor age (hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.01, 1.05), recipient age 47 years or older (HR 1.03; 95% CI, 1.02, 1.04), and male sex (HR, 1.19; 95% CI, 1.02, 1.39) portended worse survival.

CONCLUSIONS

Barriers in consenting practices, concerns about organ function, and recipient survival prevent the widespread use of aged allografts for lung transplantation. Better understanding of factors associated with worse outcomes of older donors and modification of organ procurement organization consenting practices may increase the use of these higher-risk donor organs.

Survey of Canadian intensivists on physician non-referral and family override of deceased organ donation

PURPOSE

Intensive care physicians play an important role in the identification and referral of potential organ donors in Canada. Nevertheless, little is known about intensivists' attitudes or behaviours in situations where families override previously expressed consent to donate; nor why physicians elect not to refer patients who are potential donors to provincial organ donation organizations (physician non-referral).

METHODS

We integrated questions regarding family override and physician non-referral into an online, self-administered survey of Canadian intensivists. We report results descriptively.

RESULTS

Fifty percent of targeted respondents (n = 550) participated. Fifty-five percent reported having witnessed family override situations and 44% reported having personally not referred patients who were potential donors. Fifty-six percent of respondents stated they would not pursue donation in the face of family override; 2% stated they would continue with the donation process. Fear of loss of trust in the donation system (81%) and obligation to respect the grief and desires of surrogate decision makers (71%) were frequently reported reasons to respect family override requests. Respondents who chose not to refer patients often did so based on organ dysfunction they assumed would preclude donation (59%), or a perception that the family was too distressed to consider donation (42%). No respondents reported that personally held beliefs against organ donation influenced their decision.

CONCLUSION

Physicians caring for patients who are potential organ donors commonly encounter both family override and physician non-referral situations. Knowledge translation of optimal practices in identification and referral could help ensure that physician practices align with legal requirements and practice recommendations.

Effect of language and country of birth on the consent process and medical suitability of potential organ donors; a linked-data cohort study 2010-2015

PURPOSE

Australia has unmet need for transplantation. We sought to assess the impact of cultural and linguistic diversity (CALD) on family consent and medical suitability for organ donation.

METHOD

Cohort study of New South Wales donor referrals, 2010-2015. Logistic regression estimated effects of primary language other than English and birthplace outside Australia (odds ratios OR, with 95% confidence intervals, 95%CI). Outcomes were whether families were asked for consent to donation, provided consent for donation, and whether the referral was medically suitable for donation.

RESULTS

Of 2977 organ donor referrals, a similar proportion of families had consent for donation was sought between non-English speakers and English speakers (p = .07), and between overseas-born compared to Australian-born referrals (p = .3). However, consent was less likely to be given for both non-English speakers than English speakers (OR 0.44, 95%CI:0.29-0.67), and those overseas-born than Australian-born (OR 0.54, 95%CI:0.41-0.72). For referrals both overseas-born and non-English speaking, families were both less likely to be asked for consent (OR 0.67; 95%CI:0.49-0.91) or give consent (OR 0.24; 95%CI0.16-0.37). There was no difference in medical suitability between English speakers and non-English speakers (p = .6), or between Australian-born and overseas-born referrals (p = .6).

CONCLUSION

Intervention to improve consent rates from CALD families may increase donation.

Crowdsourced analysis of factors and misconceptions associated with parental willingness to donate their child's organs

We evaluated factors associated with a parental willingness to donate their child's organs. A twenty-one-question survey was administered to US parents with at least one child to measure organ donation acceptability and brain death beliefs using an online crowdsourcing medium, Amazon's Mechanical Turk Prime. We collected 425 surveys; 76% were willing to donate their own and 65% willing to donate their child's organs. Parents who agreed brain death was synonymous with death (47%) were 2.37 times more willing to donate. Compared with White respondents, Black (OR 5.27, CI 2.81, 9.88) and Hispanic (OR 2.24, CI 1.06-4.75) participants were more likely to believe doctors "steal organs from patients" and "declare someone dead based on their skin color" (OR 4.97, CI 2.65-9.32; OR 2.19, CI 1.01-4.72, respectively). Lower income participants were also more likely to believe doctors "steal organs from patients," OR 0.81 (95% CI 0.68-0.96 for increasing income) and "declare someone dead based on how much money they have," OR 0.80 (95% CI 0.67-0.96 for increasing income). Confusion surrounding brain death and skepticism (particularly among racial and ethnic minorities and lower socioeconomic groups) toward doctors' motivations for donation contribute to lack of parental willingness to donate.

Disparities in Acceptance of Deceased Donor Kidneys Between the United States and France and Estimated Effects of Increased US Acceptance

IMPORTANCE

Approximately 3500 donated kidneys are discarded in the United States each year, drawing concern from Medicare and advocacy groups.

OBJECTIVE

To estimate the effects of more aggressive allograft acceptance practices on the donor pool and allograft survival for the population of US wait-listed kidney transplant candidates.

DESIGN, SETTING, AND PARTICIPANTS

A nationwide study using validated registries from the United States and France comprising comprehensive cohorts of deceased donors with organs offered to kidney transplant centers between January 1, 2004, and December 31, 2014. Data were analyzed between September 1, 2018, and April 5, 2019.

MAIN OUTCOMES AND MEASURES

The primary outcome was kidney allograft discard. The secondary outcome was allograft failure after transplantation. We used logistic regression to model organ acceptance and discard practices in both countries. We then quantified using computer simulation models the number of kidneys discarded in the United States that a more aggressive system would have instead used for transplantation. Finally, based on actual survival data, we quantified the additional years of allograft life that a redesigned US system would have saved.

FINDINGS

In the United States, 156 089 kidneys were recovered from deceased donors between 2004 and 2014, of which 128 102 were transplanted, and 27 987 (17.9%) were discarded. In France, among the 29 984 kidneys recovered between 2004 and 2014, 27 252 were transplanted, and 2732 (9.1%, P < .001 vs United States) were discarded. The mean (SD) age of kidneys transplanted in the United States was 36.51 (17.02) years vs 50.91 (17.34) years in France (P < .001). Kidney quality showed little change in the United States over time (mean [SD] kidney donor risk index [KDRI], 1.30 [0.48] in 2004 vs 1.32 [0.46] in 2014), whereas a steadily rising KDRI in France reflected a temporal trend of more aggressive organ use (mean [SD] KDRI, 1.37 [0.47] in 2004 vs 1.74 [0.72] in 2014; P < .001). We applied the French-based allocation model to the population of US deceased donor kidneys and found that 17 435 (62%) of kidneys discarded in the United States would have instead been transplanted under the French system. We further determined that a redesigned system with more aggressive organ acceptance practices would generate an additional 132 445 allograft life-years in the United States over the 10-year observation period.

CONCLUSIONS AND RELEVANCE

Greater acceptance of kidneys from deceased donors who are older and have more comorbidities could provide major survival benefits to the population of US wait-listed patients.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03723668.

Family First: Asian Americans' Attitudes and Behaviors Toward Deceased Organ Donation

Asian Americans have substantial transplantation needs but have the lowest rates of organ donation in the USA. As the shortage of transplantable organs persists, the rate of deceased donation by Asian Americans has not kept pace with that of the general population. This report is a qualitative study of organ donation-related attitudes and beliefs of three Asian ethnic groups located in the greater Philadelphia metropolitan area: Chinese, Filipino, and Vietnamese Americans. Guided by a Community Advisory Board representing these groups, we conducted 9 focus groups with a total of 64 participants and subsequent thematic analyses. Six major themes emerged: (1) positive views about organ donation, (2) previous exposure to organ donation, (3) primacy of the family in decision making, (4) mistrust of the healthcare and donation systems, (5) religious and cultural beliefs concerning the body, and (6) isolation from mainstream American society. Although participants expressed commonalities and beliefs in line with other American racial and ethnic groups, we also identified unique beliefs, such as familial influence, religious and cultural concerns regarding body wholeness and the dead, and underlying reasons for medical mistrust, such as a belief in a black market. The study's findings challenge the dominant educational and awareness campaigns about organ donation decision making that focus on individual autonomy and overlook the need for incorporating the specific content and message delivery needs of Asian Americans. This study is the first to explore attitudes and knowledge about posthumous organ donation among US Asian American populations in at least a decade.

Moving from the HIV Organ Policy Equity Act to HIV Organ Policy Equity in action: changing practice and challenging stigma

PURPOSE OF REVIEW

The HIV Organ Policy Equity (HOPE) Act, signed in 2013, reversed the federal ban on HIV-to-HIV transplantation. In this review, we examine the progress in HOPE implementation, the current status of HIV-to-HIV transplantation, and remaining challenges.

RECENT FINDINGS

Pursuant to the HOPE Act, the Department of Health and Human Services revised federal regulations to allow HIV-to-HIV transplants under research protocols adherent to criteria published by the National Institutes of Health. The first HIV-to-HIV kidney and liver transplants were performed at Johns Hopkins in March of 2016. Legal and practical challenges remain. Further efforts are needed to educate potential HIV+ donors and to support Organ Procurement Organizations. As of November 2017, there are 22 transplant centers approved to perform HIV-to-HIV transplants in 10 United Network for Organ Sharing regions. To date, 16 Organ Procurement Organizations in 22 states have evaluated HIV+ donors. The National Institutes of Health-funded HOPE in Action: A Multicenter Clinical Trial of HIV-to-HIV Deceased Donor (HIVDD) Kidney Transplantation Kidney Trial will launch at 19 transplant centers in December of 2017. A HOPE in Action Multicenter HIVDD Liver Trial is in development.

SUMMARY

Significant progress toward full HOPE implementation has been made though barriers remain. Some challenges are unique to HIV-HIV transplantation, whereas others are amplifications of issues across the current transplant system. In addition to a public health benefit for all transplant candidates in the United States, partnership on the HOPE Act has the potential to address systemic challenges to national donation and transplantation.

Illinois Department of Motor Vehicle Customers’ Reasons for (Not) Registering as an Organ Donor

Context:

Organ donation campaigns are maximized when promotional messages address salient issues among the intended audience. A diverse sample (N = 1573) was recruited to identify the reasons for (not) registering as an organ donor.

Objective:

Relying on an established coding scheme, an updated explanation for why individuals register (or not) as organ donors is provided. Moreover, registration trends with respect to race, biological sex, and age is presented.

Method:

Participants exiting Department of Motor Vehicle offices (N = 12) were surveyed to understand their reasons for registering and not registering as organ donors.

Results:

Benefits of donation followed by prior registration, rational arguments, and personal experiences represented nearly 90% of the coded responses for registering. Conversely, negative beliefs, decisional uncertainty, perceived disqualification, no reason, general fear/disgust, and lack of opportunity constituted nearly 90% of the coded responses for not registering as an organ donor. Whites and Latinx individuals were more likely to register as organ donors compared to African Americans. Participants in the lower (18-24) and upper (65+) age brackets had the lowest donor registration rates.

Conclusion:

Promotional efforts should continue to target younger and older audience segments with information about organ donation as well as African Americans. Results from the current study suggest emphasizing the benefits of organ donation as well as overcoming negative beliefs, decisional uncertainty, and perceived disqualifications.

Organ donation in trauma victims: A systematic review and meta-analysis

BACKGROUND

Although trauma patients represent a large pool of potential organ donors (PODs), the donor conversion rates (DCRs) in this population are unclear. Our primary objective was to synthesize published evidence on DCRs in trauma patients. As a secondary objective, we investigated factors that affect organ donation (OD) in the trauma population.

METHODS

We searched four electronic databases (PubMed, Embase, Web of Science, and Cochrane Library) and gray literature for articles on OD in trauma patients (PROSPERO 2017: CRD42017070388). Articles were excluded if it was not possible to calculate the DCR (actual organ donors divided by PODs). We pooled DCRs and performed subgroups analysis by trauma subpopulation, patients' age, and study publication date.

RESULTS

We identified 27 articles with a total of 123,142 participants. Cohorts ranged in size from 28 to 120,512 patients (median, 132), with most studies performed in the United States. Conversion rates among individual studies ranged from 14.0% to 75.2% (median, 49.3%). All 27 studies were included in the meta-analysis. We found a pooled DCR of 48.1% using the random effects model. There was a high level of heterogeneity between studies (I = 97.4%). Upon subgroup analysis, we found DCRs were higher in head trauma patients compared with traumatic cardiac arrest patients (45.3% vs 20.9%, p < 0.001), in pediatric patients compared with adults (61.0% vs 38.0%, p = 0.018), and in studies published after 2007 compared with those published before (50.8% vs 43.9%, p < 0.001). Few studies assessed for factors associated with OD in trauma patients.

CONCLUSIONS

We found variation in DCRs among trauma patients (range, 14.0-75.2%) and estimated a pooled DCR of 48.1%. Our results are limited by heterogeneity across studies, which may be attributable to differences in study design and population, definitions of a POD, and in the institutional criteria and processes regarding OD.

LEVEL OF EVIDENCE

Systematic reviews and meta-analyses level III.

Changing Metrics of Organ Procurement Organization Performance in Order to Increase Organ Donation Rates in the United States

The shortage of deceased-donor organs is compounded by donation metrics that fail to account for the total pool of possible donors, leading to ambiguous donor statistics. We sought to assess potential metrics of organ procurement organizations (OPOs) utilizing data from the Nationwide Inpatient Sample (NIS) from 2009-2012 and State Inpatient Databases (SIDs) from 2008-2014. A possible donor was defined as a ventilated inpatient death ≤75 years of age, without multi-organ system failure, sepsis, or cancer, whose cause of death was consistent with organ donation. These estimates were compared to patient-level data from chart review from two large OPOs. Among 2,907,658 inpatient deaths from 2009-2012, 96,028 (3.3%) were a "possible deceased-organ donor." The two proposed metrics of OPO performance were: (1) donation percentage (percentage of possible deceased-donors who become actual donors; range: 20.0-57.0%); and (2) organs transplanted per possible donor (range: 0.52-1.74). These metrics allow for comparisons of OPO performance and geographic-level donation rates, and identify areas in greatest need of interventions to improve donation rates. We demonstrate that administrative data can be used to identify possible deceased donors in the US and could be a data source for CMS to implement new OPO performance metrics in a standardized fashion.

Familial Consent for Deceased Organ Donation Among Immigrants and Long-term Residents in Ontario, Canada: A Population-Based Retrospective Cohort Study

Background

Many families choose not to consent to organ donation at the time of their loved one's death. In Ontario, Canada, whether these decisions vary by ethnicity remains unclear.

Objective

To compare the proportion of families of immigrants who consented for deceased organ donation with families of long-term residents.

Design

Population-based retrospective cohort study.

Setting

Potential donors in Ontario, Canada, between November 2008 and March 2013.

Methods

We used linked administrative databases to study the proportion of families who consented for deceased organ donation.

Results

Overall, of the 2873 families of potential donors approached, 1912 (67%) provided consent for deceased organ donation. Families of immigrants were less likely to provide consent compared with families of long-term residents (46% [135 of 291] vs 69% [1777 of 2582]; adjusted rate ratio (RR): 0.72; 95% confidence interval [CI]: 0.63-0.81). When examined by the country of birth, families of immigrants from the following regions were less likely to consent to organ donation compared with long-term residents: South Asia (RR: 0.71; 95% CI: 0.55-0.91), East Asia and Pacific (RR: 0.68; 95% CI: 0.53-0.88) and Middle East, North Africa, and sub-Saharan Africa (RR: 0.58; 95% CI: 0.37-0.91).

Limitations

We could not determine why consent was not obtained. We had a small sample of immigrants. We only had access to the potential donors' information and not the family member who was approached for consent. Many characteristics that we examined were nonmodifiable (eg, age, sex).

Conclusions

In Ontario, families of immigrants are less likely to consent to deceased organ donation. There is an opportunity to better understand the reasons for lower consent among certain immigrant groups.

Peer Leaders Increase Organ Donor Designation Among Members of Historically African American Fraternities and Sororities

Introduction:

Health education programs can positively impact organ donor designation among African Americans, a disproportionately represented group on the transplant waiting list. Alumni chapters of historically African American sororities and fraternities are a novel setting for organ donation education and research.

Research Questions:

This study tested the effectiveness of a lay health advisor model to increase donor designation registrations on the Michigan Organ Donor Registry among members of Midwest alumni chapters. The secondary outcome was change in attitudes toward donation assessed by pre–post questionnaire.

Design:

Sorority/fraternity members were trained to deliver educational presentations during a 12-month period. Follow-up messaging consisted of tailored newsletters and e-mails. A cluster randomized design was utilized with 25 chapters (16 sororities and 9 fraternities) assigned to intervention (organ donation) or comparison (chronic disease).

Results:

Odds of signing up for the donor registry were 1.45 times higher for the intervention group than the comparison group. Among those identified as nondonors at baseline, the odds of signing up were 1.58 times higher for intervention than comparison.

Discussion:

Using lay health advisors in African American sororities and fraternities can increase enrollment in a donor registry. Alumni chapters offer a unique and viable setting for organ donation education and research; relationship building with chapter officials is key to success.

Fresh osteochondral allografts-procurement and tissue donation in Europe

Fresh osteochondral allografts are a well-established treatment for large, full-thickness cartilage defects. The clinical outcome for carefully selected patients is very favorable, especially for the young and active and graft survival up to 25 years has been described in the literature. Furthermore, a high patient satisfaction rate has been reported, but the biggest obstacle to overcome is the availability of tissue for transplantation. Large fresh bone allografts for cartilage damage repair only can be harvested from organ donors following organ removal or cadaveric donors, preferably in the setting of an operation room to minimize possible contamination of the tissue. Apart from the logistic challenges this entails, an experienced recovery team is needed. Furthermore, the public as well as medical staff is much less aware of the possibility and requirements of tissue donation than organ donation and families of deceased are rarely approached for bone and cartilage donation. This review aims to highlight the current situation of organ and tissue donation in Europe with special focus on the processing of bones and possible safety and quality concerns. We analyze what may prevent consent and what might be done to improve the situation of tissue donation.

Hospital characteristics associated with increased conversion rates among organ donors in New England

BACKGROUND

It is unknown whether hospital characteristics affect institutional performance with regard to organ donation. We sought to determine which hospital- and patient-level characteristics are associated with high organ donor conversion rates after brain death (DBD).

METHODS

Data were extracted from the regional Organ Procurement Organization (2011-2014) and other sources. Hospitals were stratified into high-conversion hospitals (HCH; upper-tertile) and low-conversion hospitals (LCH; lower-tertile) according to conversion rates. Hospital- and patient-characteristics were compared between groups.

RESULTS

There were 564 potential DBD donors in 27 hospitals. Conversion rates differed between hospitals in different states (p < 0.001). HCH were more likely to be small (median bed size 194 vs. 337; p = 0.024), non-teaching hospitals (40% vs. 88%; p = 0.025), non-trauma center (30% vs. 77%; p = 0.040). Potential donors differed between HCH and LCH in race (p < 0.01) and mechanism of injury/disease process (p < 0.01).

CONCLUSION

There is significant variation between hospitals in terms of organ donor conversion rates. This suggests that there is a pool of potential donors in large specialized hospitals that are not successfully converted to DBD.

Transcendental Spirituality and Acquaintance With the Activities of the Domestic National Transplant Center as Factors Shaping Attitudes Toward Organ Donation

Context:

Organ donation has been shown to be perceived as inappropriate by religiously observant individuals. The impact of spirituality level on attitudes toward organ donation has not been broadly explored.

Objective:

To explore the contribution of ethnicity, spirituality, level of religious observance, and acquaintance with the activities of the Israel National Transplant Center (INTC) to forming attitudes toward organ donation among Jews and Muslim Arabs in Israel.

Design:

A descriptive cross-sectional survey.

Participants:

Three hundred five (65.2%) Jewish and 163 (34.8%) Muslim Arab respondents living in Israel.

Results:

Jewish respondents had more positive attitudes toward organ donation than Muslim Arabs. Muslim Arabs had a higher mean spirituality score than Jews. Gender, age, ethnicity, level of religious observance, education, 4 spirituality dimensions, and acquaintance with the activities of the INTC explained 41.5% of the variance in attitudes to organ donation. Transcendental spirituality, acquaintance with the activities of the INTC, and level of religious observance had the highest contribution to explaining attitudes to organ donation, while gender and age had a low contribution. Ethnicity, education, and the 3 other spirituality dimensions were not found to have a significant contribution.

Conclusion:

A multifaceted approach to improving attitudes toward organ donation among Jews and Muslim Arabs in Israel is important.

The case against imminent death donation

PURPOSE OF REVIEW

Imminent death donation (IDD) is a proposal to procure organs from patients prior to the withdrawal of life support, which is anticipated to lead to death. In this review, we outline substantial concerns that the transplant community should consider when deliberating the possibility of practicing IDD.

RECENT FINDINGS

Although there are several compelling theoretical and intuitive reasons to support IDD, its application has been hindered because of inadequate definitions or protocols. A lack of published reports limits empirical data about the practice. Discussion on the topic has not adequately addressed potential harms to the donor, involvement of stakeholders, or the threat to public trust.

SUMMARY

Although IDD has been proposed as a method to increase the number of organs or improve end-of-life care, the proposal currently poses more risk than benefit for patients and the transplant community. Until the major barriers to implementation of IDD are addressed, the transplant community should invest its efforts to increase the organ supply elsewhere.