The impact of donor policies in Europe: a steady increase, but not everywhere

Remco Coppen 2 Roland D Friele 1 2 Sjef KM Gevers 0 Geke A Blok 4 Jouke van der Zee 2 3 0 Department of Social Medicine, Health Law Section, Academic Medical Center/University of Amsterdam , Amsterdam , The Netherlands 1 Tranzo, Tilburg University , Tilburg , The Netherlands 2 NIVEL, Netherlands Institute for Health Services Research , PO Box 1568, 3500 BN Utrecht , The Netherlands 3 Faculty of Health Sciences, Department of Medical Sociology, University of Maastricht , Maastricht , The Netherlands 4 Faculty of Health Sciences, Department of Educational Development and Research, University of Maastricht , Maastricht , The Netherlands Background: Transplantable organs are scarce everywhere. Therefore, countries have developed policies to support the efficient use of potential donors. Nevertheless, the shortage of organs remains. Were these policies in vain? The aim of this study is to assess the impact of donor policies on donor procurement in 10 Western European countries from 1995 to 2005. Method: To assess the impact of the donor policies we studied the conversion of potential donors into effectuated donors. 80% of the donors died from CVAs or a (traffic) accident. We considered these mortality rates to be a good proxy for potential donors. Here we call the conversion of potential donors into actual donors 'the donor efficiency rate by proxy'. Results: The mortality rates for CVA and (traffic) accidents have decreased in the countries under study. At the same time, in most countries the donor efficiency rates have steadily increased. The variance in donor efficiency rates between countries has also increased from 1995 to 2005. Four countries introduced a new consent system or changed their existing system, without (visible) longterm effects. Conclusion: The overall increase in donor efficiency means that the efforts to improve donor policies have paid off. However, substantial differences between countries were found. The success of donor policies in terms of the number of absolute donors is blurred by the success of policies on traffic safety and CVA treatment. It remains unclear which specific policy measures are responsible for the increase in donor efficiency rates. This increase is not related to having a presumed consent system. Furthermore, an analysis of countries that introduced a new consent system or changed their system showed no effect on donor efficiency. - Background Transplantable organs are scarce throughout the world. The discrepancy between the number of people listed on a national organ transplant waiting list and the number of post mortem organ donations per year results in long waiting times for patients to receive an organ [1,2]. In other words, the supply of organs that can be used for a transplant does not meet the need. The urgency of this problem was once again addressed by the EU Health Commissioner Markos Kyprianou in 2007 [3]. To deal with the scarcity of organs, countries have developed national organ donation policies. In most countries these donor policies consist of a legislative system which regulates consent for donation [4] and additional policy measures. Basically, there are two kinds of legislative systems: explicit consent and presumed consent. In an explicit consent system, the donor has to authorize organ removal after his death in the form of an advance directive or a codicil, or by registration in a national registry. If the deceased's wishes are unknown, next of kin are asked to consent. A presumed consent system does not require to obtain consent, either from the donor or from the next of kin; it is sufficient to verify that the deceased has not objected during his lifetime to becoming a donor [4]. In all countries, the group of non-registered residents is larger than the group of registered residents. Thus, presumed consent countries have larger pools of donor-consent than explicit consent countries, which might automatically result in greater numbers of donors in the former. Several authors have argued that differences in organ donation rates between consent systems prove that a presumed consent system leads to a more effective procurement of donors [5-7]. Other policy measures are directed at optimizing the process of donor procurement. Examples of such measures are hospital programs like Donor Action [8,9]. and EDHEP [10], or informing the public about the relevant aspects of organ donation [11,12]. To optimize the process of donor procurement, Spain developed an organizational model ('the Spanish model') with policy measures on national, regional, and hospital level to address the importance of organ donation and to effectively convert potential donors into actual donors [13-15]. In many countries these efforts have intensified over time. However, the shortage of organ donors remains. According to several studies [1,6,16,17]. the number of organ donations per million inhabitants (PMI) has increased only in some countries, whereas in most countries it has been stable or even decreased. Were these policy measures in vain? An international comparison of the performance of countries with regard to donor procurement over the years may provide some insight into the impact of policy measures in general. To assess the impact of donor policies and to compare the performance of the different countries, a valid and reliable measure is needed. In many studies the national donation rates PMI are used. Several studies have demonstrated that using the number of donors PMI does not produce a valid comparison [1,18-30]. There are significant differences in the number of potential donors between countries, e.g. in the numbers of people dying from a CVA or (traffic) accident. Therefore, a measure which expresses the conversion of potential donors into effectuated donors PMI produces a more valid comparison than only the number of effectuated donors as a whole. The aim of this study is to assess the impact of the donor policies in 10 Western European countries on donor procurement from 1995 until 2005. This study is part of the national evaluation of the Dutch Organ Donation Act [31]. Method Population To assess the impact of the donor policies we studied the conversion of potential donors into effectuated donors in 10 Western European countries. The number of confounding factors between countries was restricted by analysing only countries which share a more or less similar historical background and have more or less the same status of health systems. The number of potential donors per country An exact measure for establishing a country's number of potential donors could be found by analysing all hospital medical records of deceased persons and identifying all potential donors [32-34]. Such data are not available for all countries. In most countries approximately 80% of donors die of a Cerebral Vascular Accident (CVA) or a traffic accident. A high correlation (Spearman's = 0.81 (P < 0.01)) has been found between these (...truncated)