The organ donation rate (DR), expressed as the number of donors per million population (pmp), is a convenient and widely used metric of the functioning of donation programs. The DR's popularity may be explained by the fact that it is easy to calculate from data readily available, and it can be used for comparing national or regional donation programs in a standardized way.1,2 This metric, however, has also drawn some criticism of being methodologically biased.1-7
It has been argued that the DR rather represents the activity (or volume) of a donation program than its performance or efficiency.1,4 The DR disregards the potential for deceased donation which ought to be taken into account when assessing the performance of a donation program,1,2,6,7 because the living population is hardly an adequate measurement parameter of such potential.6
Many different methodologies have been proposed for a more realistic assessment of the potential for deceased organ donation, and for a metric of the efficiency of donation programs.2-4,7-25 Broadly summarized, these studies have 2 things in common. First, there is widespread agreement that a more accurate assessment of the donor potential is needed, and that it ought to focus on deaths from causes likely leading to brain death (BD). Second, no consensus has been reached on how to best estimate or determine the potential for deceased organ donation. Most studies have chosen different approaches for its assessment, due to methodological and practical considerations (eg, data availability or comparability), or the lack of generally accepted definitions.1,3,14,19
Despite the methodological issues, these studies have succeeded in drawing the attention to the fact that there are considerable differences among regions or countries in terms of mortality rates (MRs) from causes that likely lead to BD, and therefore also in the potential for deceased organ donation.4,10,13,18,26,27 As fatalities from causes associated with BD (broadly, cerebrovascular accidents, trauma and anoxia) vary internationally as well as in countries over time, MRs from these causes most likely also have an impact on the potential. Consequently, it has been argued that an assessment of the performance or efficiency of donation programs should account for such variabilities in the potential.10,11,13,18
In this article, we present a comparison of donation activity and efficiency of donation programs internationally, as well as in individual countries over time. For this comparison, we used deceased organ donation and mortality registry data, from which we calculated a donor conversion index (DCI) for each country and year. The aim of this retrospective data analysis including 27 Council of Europe countries and the United States was threefold. First, we wanted to assess the potential for deceased organ donation based on selected mortality data (which we used as basis for the DCI). Second, we intended to assess whether there are differences between DRs pmp and the DCI (activity vs efficiency). Third, we aimed at providing an overview of the evolution of the donation efficiency of different countries over time.
MATERIALS AND METHODS
This is a retrospective analysis of 2001 to 2015 deceased organ donation and mortality data. The analysis includes 27 Council of Europe countries and the United States. We used the “donor efficiency rate by proxy” by Coppen et al.18 as a model which we adapted slightly for the calculation of the DCI, and the assessment of donation program performance over time and in international comparisons. Our slightly adapted model indicates how many actual deceased donors (ADDs) resulted from 100 deaths from the causes associated with potentially devastating cerebral lesions related to BD.8,11
Data Sources and Definitions
Deceased donation data was provided by the Organización Nacional de Trasplantes from the Council of Europe Newsletter Transplant database. All deceased donation figures presented in this study are ADDs, defined as deceased persons from whom at least 1 organ has been recovered for the purpose of transplantation.28 Donation rate pmp presented in this study may vary slightly from figures published elsewhere as they were calculated from the annual number of ADDs reported by each country to the Newsletter Transplant, and from Eurostat and United States Census Bureau population data for each corresponding year.29,30 If donation after cardiocirculatory death (DCD) country data in the Newsletter Transplant database was either blank or zero for all years during the entire study period, a country was categorized as not having had an active DCD program. In the Newsletter Transplant database, DCD data for 2001 to 2002 was not reported separately.
European population data were extracted from the Eurostat database.29 US population data were extracted from the United States Census Bureau database.30 The data used were the resident population on January 1 of each year, except for 2001 to 2009 US data (July 1).
European mortality data (absolute number of fatalities per year and country; all ages, not age standardized) was extracted from the Eurostat database.29 Corresponding US mortality data were extracted from the National Center for Health Statistics database.31
The selection of mortality data relevant for deceased organ donation was based on the European Directorate for the Quality of Medicines & HealthCare's “Guide to the quality and safety of organs for transplantation” (Table 2.3: International Classification of Diseases [ICD]-10 codes of diseases associated with potentially devastating cerebral lesions related to BD).8 For the purpose of the DCI calculation, the following ICD-10 codes32 were used:
- I60-I69 (cerebrovascular diseases). Covers cerebrovascular accidents (I60-I66).
- G00-H95 (other diseases of the nervous system and the sense organs), excluding G20 (Parkinson disease) and G30 (Alzheimer disease). Covers all cerebral damages (anoxic brain damage, compression of brain, cerebral edema, and infections of the central nervous system (meningitis)).
- V01-V99, Y85 (transport accidents) was used as a substitute for trauma because the corresponding ICD-10 codes (S02, S06) were not available.
Cerebral neoplasms were excluded due to a relatively high number of fatalities out of which only a small percentage are relevant for deceased organ donation. Moreover, data on the relevant causes (C71, D33) was only available as part of larger packages of aggregated data including various other fatalities.
Handling of Missing Data
Missing mortality data were imputed using the TREND function in Microsoft Excel 2013 (method of least squares). If no preceding data were available (first year of the study period), the 3 subsequent values were used. If there was a data gap, the 3 preceding and the 3 subsequent values were included and the mean of the 2 predicted values was taken.
Calculation of DCI
The DCI expresses the absolute number of ADDs per country and year as a percentage of the absolute number of fatalities belonging to the selected ICD-10 codes per country and year. The DCI indicates how many ADDs resulted from 100 deaths from the causes associated with potentially devastating cerebral lesions related to BD.8 For example, a 3% DCI equals 3 ADDs that resulted from 100 fatalities from the selected causes.
Table 1 shows 2001 to 2015 data (DCI, DR, and MR from the selected causes) for the 28 countries included in the study. Figure 1 illustrates the differences when comparing the 2015 country rankings by DRs and DCI. An overview on the evolution and significance of individual national DCD programs is presented in Table 2. Figure 2 shows the development of donation efficiency according to the DCI over time by country.
Donor Conversion Index
The DCI indicated that there were differences in donation efficiency between the countries as well as in individual countries during the 15 years analyzed (Table 1, Figure 2).
In 2015, the DCI was highest by far in Spain (5.0%), followed by France and the United States (3.9% both), Belgium (3.7%), Ireland (3.1%), and Austria (3.0%). According to the DCI, these programs were the most efficient of all countries included in the study. Figure 2 shows that there were considerable differences in efficiency not only between the countries, but also in individual countries over time. The countries with the highest DCI increase (2001 vs 2015) were Spain (+2.1 percentage points), France (+1.9 percentage points), and Belgium (+1.8 percentage points).
The MR per 100 000 population from the causes associated with BD decreased in most countries during the study period, however to different degrees (Table 1). Estonia and Portugal were among the countries that showed the most considerable reduction in MRs over time. Notable exceptions were Bulgaria, Lithuania, and Slovakia where MRs increased when comparing 2001 with 2015 data.
Donation rates showed sizeable differences in international comparisons. The DR increased in a majority of countries during the evaluation period, however to different degrees (Table 1). Donation rates increased substantially during the evaluation period in Croatia, Portugal, and Slovenia. Countries with the highest DRs at the end of the study period included Croatia, Spain, Belgium, Portugal, the United States, and France.
Donation Activity Versus Efficiency
Figure 1 shows the differences when comparing the 2015 country rankings by DR and DCI. Countries are ordered based on the difference when ranked according to DR versus DCI. The figure illustrates that the DR can fail to represent performance, particularly for countries in which the mortality relevant for organ donation is low or high. Countries on the left side of the chart (positive rank difference) were ranked higher by DCI than by DR. For example, Ireland was on position 5 (fifth highest) of the countries ranked by DCI, but only on position 16 ranked by DR. This comparison shows that in countries with a large positive or negative ranking difference, there is a disparity between the donation activity and the efficiency.
Countries with a high DR pmp but only an intermediate DCI in 2015 included Croatia (40.0 pmp DR, 2.0% DCI) and Portugal (30.7 pmp DR, 2.3% DCI). In these 2 countries, only a moderate proportion of the supposed potential for deceased organ donation was actually converted into actual donation, regardless of the fact that the DRs were among the highest in international comparisons. In contrast, there were national donation programs with an intermediate DR but a relatively high DCI. In 2015, these included Austria (23.2 pmp DR, 3.0% DCI), Ireland (17.5 pmp DR, 3.1% DCI), and Switzerland (17.4 pmp DR, 2.7% DCI). In these countries, the potential was transformed quite efficiently, even though they did not belong to the nations with the highest DRs.
Donation After Cardiocirculatory Death
Table 2 shows that 17 out of 28 countries reported DCD donors during the evaluation period. It shows the absolute number of DCD donors per year as well as a percentage of the total number of ADDs. Countries with the most active DCD programs at the end of the study period were the Netherlands, the United Kingdom, Latvia, Belgium, Spain, the United States, and Switzerland.
The Netherlands, Latvia, and Belgium showed virtually no or little increase in the conversion of donation after BD (DBD) over the study period (Figure 2). Similarly, the UK's DCI increase was mainly due to the considerable growth of DCD. In the United States, the introduction of DCD in 2011 led to a subsequent decrease of the DBD portion of the DCI.
The data presented in our study suggest that there are considerable differences in the potential and the efficiency of donation programs among countries as well as over time in individual countries. Although it is widely publicized that DRs vary substantially between countries, the differences in MRs from causes relevant to the potential for deceased organ donation usually draw much less attention. However, our figures show that large differences in MRs exist between the countries, even though most succeeded in reducing fatalities relevant to the potential for deceased organ donation during the 15 years analyzed.
When comparing DRs and DCI data (ie, donation activity vs efficiency) in 2015, there were also notable differences among the national donation programs. In our study, we found that Spain has been and continues to be at the forefront of countries with both the most active and efficient deceased organ donation programs. France, the United States, Belgium, Ireland, and Austria also have efficient donation programs according to the DCI. We also found that, with a few exceptions, most countries succeeded in increasing the donation efficiency over time, even though to different degrees.
Donor Conversion Index
The DCI puts the number of ADDs (donation activity or volume) in relation to the approximated potential for deceased organ donation (number of fatalities from causes associated with BD).8 As such, the DCI can be used as a metric of a donation program's performance. The efficiency can increase if there is a reduction of MR (while keeping the donation activity stable), or an increase of the donation volume (if the mortality is stable), or a combination of both. Most countries in our study succeeded in increasing the donation efficiency, however by different means and measures.10,20,33-41
Factors With a Possible Influence on the DCI
Clearly, there are many crucial steps in the donation process between the potential for deceased organ donation and the final result, ie, ADDs. These steps include (but are not limited to) the detection and referral of possible donors, organizational structures, and obtaining consent to donation.11,15,17,38,39,42-45 Therefore, many factors may influence the donation efficiency. For example, a lack of (in- or out-of-hospital) infrastructure, neurosurgical facilities, or a lack of financial or human resources, and the absence of training or accountability.
Because the efficiency depends on the potential for deceased organ donation, success of measures that enhance public health and road traffic safety, as well as progress in the treatment of traumatic brain injury and cerebrovascular accidents may influence the DCI. The data presented in our study suggests, however, that there is no direct connection between the reduction of fatalities and the donation efficiency which is in line with findings in previous studies.13,18
There are various factors that may influence the donation activity as well as the efficiency. For example, the introduction of a DCD program, or an increased acceptance of extended criteria and/or older donors.33,34,39,46,47 Recent studies show that in 2015, 10% of donors in Spain were aged 80 years and older, and that in Spain as well as in France a considerable proportion of deceased donors (≈1/3) are 65 years or older.33,47
Another major reason for differences in DCI among donation programs are variations in consent rates. However, there is no generally accepted formula for the calculation of the consent rates, and only 14 of 28 countries included in this study are reporting consent rates to the Newsletter Transplant.19,28 This makes an international comparison virtually impossible, despite the fact that in countries with a low consent rate the negative impact on the DCI may be very strong.48-50
The differences in MRs among the countries show that the potential for deceased organ donation is far from being the same everywhere. This points to the importance of taking into account the potential when assessing the performance of donation programs, as emphasized by previous studies.2-4,7-25
The reduction of deaths from the selected causes in most countries can likely be explained by measures that enhance public health, and better prevention of transportation fatalities.18,27,51-53 Such measures likely result in a reduction of the maximum potential for deceased organ donation.1,12,13,27,51,52,54 Without going into detail, we found no apparent relation between a reduction of the MRs and the performance of donation programs. In a broad way, this is in line with previous findings, even if results are not directly comparable due to methodological incongruence. However, high MRs may be an indicator for a not so well developed public health service (likely due to a lack of resources) and therefore, organ donation and transplantation might not be on top of the priority list.
DRs Versus DCI
It is widely known that there are sizeable differences in DRs pmp between countries.28,37 In our comparison of donation activity versus efficiency, we found that some countries have a high DR as well as a high DCI (eg, Spain, France, the United States, and Belgium). Generally speaking, however, there was no direct relation between the DR and the DCI, because the latter takes into account variabilities in mortality. As shown in the comparison of the 2015 DR versus DCI ranking, countries with a large number of donors (high activity) but also a large number of fatalities from the selected causes (high potential) show the largest discrepancy between activity and efficiency. A multitude of factors may have an impact on the donation activity as well as efficiency. The primary scope of the DCI is to provide a benchmark for comparing the efficiency of different programs. Differences in efficiency may be explained by various reasons. These may include, among others, variances in access to healthcare in general, access to intensive care and place of death, consent rates and modality, or organizational aspects of the organ donation and transplant programs. Further studies are required for an analysis of the impact of such factors on the donation efficiency.
Donation After Cardiocirculatory Death
There is some controversy in the literature whether (or how) the promotion of DCD programs is influencing the DBD activity.55-59 The data presented in our study show that in some countries, the increase in the DCI resulted from an increase of both, DBD and DCD. In other countries, the DBD efficiency remained mostly stable over time and the increase in DCI resulted basically from DCD. Remarkably, the United States showed an unparalleled drop in DBD performance after the introduction of DCD in 2011.
Because DCD may also result from deaths that are not included in the selected causes likely leading to BD, the DCI for DCD must be interpreted with caution. Especially, this applies to countries with a substantial proportion of DCD. In these donation programs, the total (DBD and DCD) value of the DCI is likely overestimated. This is due to the fact that the DCI is calculated based on mortality associated with BD. However, DCD may also result from fatalities that are not covered by these selected causes of death.
Also, one should keep in mind that DCD is a resource-intensive process, and that the organ yield per donor is lower than in DBD.34,55-57,60 Therefore, the DCD potential should be supplementary to the DBD potential.
Study Strengths and Limitations
The DCI used in this paper for an assessment of the donation efficiency has its strengths and limitations. Compared with DRs, the main advantage of the DCI is that it takes into account the potential for deceased organ donation (actual mortality from the selected causes). Therefore, the DCI may be considered more suitable for a performance comparison of donation programs. Yet, the DCI is not meant to replace the DR pmp but rather as a complementary indicator of the efficiency of a program. We believe that the DCI can provide important insight concerning the conversion of the potential into donors that may help donor programs to improve the donation performance.
The DCI's main advantage over the DR is that it is not subject to population size change (eg, due to migration, and varying birth or overall MRs) which has no direct impact on neither the donation activity nor efficiency.1,6 In addition, the DCI's meaning is easy to grasp: The increase of the DCI by 1 percentage point means that there was 1 more donor of 100 deaths from the relevant causes.
Compared with alternative methods used in other studies to estimate or determine the potential for deceased organ donation, the DCI has also some distinctions. In addition to cerebrovascular disease and traffic accident mortality (used in some studies as a proxy), the DCI also covers cerebral damages of other causes. Also, in contrast with studies that determined the potential for donation by medical chart review, the DCI can be calculated from standardized database information (IDC codes) readily available for many countries worldwide.
Major limitations of the DCI include (in addition to the points discussed in “Factors With a Possible Influence on the DCI,” and limitations concerning DCD): The mortality data used for the DCI calculation allows only for an estimation of the potential for deceased organ donation. In the online Eurostat database, some of the relevant ICD codes were only available as part of larger groups (data packages) which may have resulted in an overestimation of the potential. Conversely, there may be an additional potential from trauma related deaths not included in the traffic accident mortality data such as work or leisure activity related accidents. In addition, we occasionally had to extrapolate missing mortality data, because some figures were unavailable).29 We consider it a minor limitation that the DCI does not account for absolute or relative contraindications. Because the DCI is calculated based on national cause of death registry data, it shares the general limitation concerning data reliability of all studies using registry information.
We are aware that the selected causes of death and the corresponding mortality allows only for an estimation of the potential for deceased organ donation. We do believe, however, that the DCI which is based on the original idea by Coppen et al.18 is useful for a performance comparison of deceased organ donation programs over time as well as internationally. In addition, the DCI can be used as an indicator for the assessment of the efficacy of measures implemented to increase organ availability. For this purpose, it is more suitable than the DR pmp because the DCI accounts for the evolution of the potential over time.
The DCI indicates that, despite a reduction of the potential, it is possible to considerably improve the efficiency of national donation programs through targeted measures. Compared with the DR pmp (which should be considered a metric for the activity, not the performance), the DCI takes into account the potential for deceased organ donation, and therefore is a more accurate metric of a donation program's efficiency. National donation programs could optimize the performance by identifying the areas where most potential is lost, and by implementing measures to tackle these issues.
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