The large rises in the number of organs donated in Spain is the result of the country’s well-organized system of transplant co-coordinators, rather than due to any changes in legislation. This success could be replicated anywhere
Globally there is an increasing demand for solid organs but the shortage of donors limits the number of patients who can benefit from transplantation. Research suggests that, primarily, the shortage is not caused by lack of suitable donors, but by failure to identify them, obtain consent and procure the organs. Partial strategies in many countries have either failed or resulted in slight or transient increases in organ donation.
The Spanish National Transplant Organisation (ONT) was set up in 1989, with a national network of specifically trained, part-time, dedicated and motivated hospital physicians to oversee the whole process of organ donation. Solid organ donors in Spain rose 550 to 1577 in absolute figures, and 14 to 34.2 organ donors per million people (PMP) in 2008 – by far the highest donor rate ever reached by an entire country. Making Spain the largest country) in the world (46.1 million inhabitants) with a continuous increase in deceased organ donation sustained over a 20-year period.
This success can be accounted for by a proactive donor detection programme performed by well-trained transplant coordinators; the introduction of systematic death audits in hospitals and the combination of:
- A positive response by society
- Adequate management of mass media relations
- Sufficient economic reimbursement for the hospitals.
The Spanish Model
This ‘Spanish Model’ has been extensively described in the medical literature and can be partial or totally adapted to other countries or regions if basic conditions are guaranteed.
The elements that come together to define the Spanish Model are transplant coordination network at three levels: national, regional and hospital. The two first levels, nominated and paid for by the National and Regional authorities are real interfaces between the political and the professional levels. All the technical decisions about transplants are taken by consensus in a Regional Council formed by the national and relevant regional authority.
At the third level is the hospital coordinator who is generally a medical doctor (although helped by nurses in the big hospitals), working in the coordinator role on a part time basis, and located inside the hospital.
The hospital coordinator
Most hospital coordinators are anaesthesiologists/intensivists with active participation in organ donation. This part-time role allows them to continue with their previous job and allows for this function to be filled even in the smaller hospitals. They are nominated by, and report to, the hospital director (rather than the head of the transplant units) and are functionally linked with the regional and national coordinators (Table I). Transplant coordinators perform continual brain death audit. Systematic prospective brain death registries, complemented by retrospective medical record reviews ensure that errors of overor underestimation of the potential donor pool are avoided. These measures have been introduced in most of the regions. The methodology includes an ongoing self audit process and the
description of the characteristics and expected rates in every hospital. It also includes the possibility of external evaluation. Once a deficit in donor detection is shown in a particular hospital or area, a detection programme is started.
Support and training
The central office of the ONT acts as the support agency in charge of organ sharing; transport; waiting list management; transplant registries; statistics; general and specialised information; and action which can improve the whole process of organ donation and transplantation.
The central Health Administration has financed and directed ongoing medical training and education for new and established transplant coordinators. It has promoted the development of training programme for health professionals, dedicated to every step of the process such as donor detection and management, legal aspects, family approach, organisational aspects, management of resources
Regional health administrations finance procurement and transplant activity. Without adequate resources the sustained procurement activity, especially for small non- university non-specialist transplant hospitals would be practically impossible. Mass media plays and important role in informing the Spanish population about these topics. Also important are the 24-hour transplantation hot line; periodic meetings between journalists and opinion leaders; training courses in communication for hospital and regional coordinators; and management of adverse publicity. The systematic dissemination of information via the media to the medical and lay community has been implemented.
An adequate definition of ‘brain dead that is similar to that of other western countries is key. No compensation can be paid either for donation or grafted organs. Spain has a theoretical presumed consent law, but from a practical point of view, the family is always consulted and the wishes of relatives respected. This is the case in practically all EU countries. Family refusal rate has been decreasing from 26% in the early 1990s to 16% in 2005. What is clear is that the increase in organ donation during the 1990s cannot be attributed to any change of the relevant Spanish legislation which has remained unmodified since 1979. Organ donation rate increased steadily throughout the 1990s and has remained between 33 and 35 donors per million population (PMP) during the past 10 years. This rate compares favourably with other Western countries and represents the greatest increase in organ donation for a whole country during this time. Fourteen out of the 17 region in Spain have more than 30 donors PMP and four of them have more than 40. The characteristics of these donors have changed. Road traffic accidents decreased as the cause of organ donation from 43% in 1992 to 8% in 2008, while strokes rose from 39 to 65.5%. Consequently, the mean age of the donors went from 38 to 54.2 years, and the percentage of donors over 60 years increased from 10 to 44%. Kidney transplants rose from 1039 to 2229 (more than 100% increase), and total solid organs transplanted from 1302 to 3943 in 20 years (3 times greater). Transplant rates from deceased donors for liver and kidney have been the highest in the world for many years and patients on the Spanish waiting list have the best chance to receive an organ.
Economics and resources
The estimated overall budget for the three levels of the coordination network is €5m per year. This figure includes salaries, administrative budgets and training courses for the central office, and salaries for regional and hospital coordination teams. The system is not homogeneous over the whole country, but in general the budget depends on the organ donation activity of each hospital. Transplant coordinators are becoming more involved in the management of resources related to organ donation and transplantation, especiallyin larger hospitals. If the annual number of kidney transplants performed in Spain had remained stable 17,000 less renal patients would have been grafted during the past 20 years. The renal replacement therapy needed to serve these patients would cost almost twice as much as all solid organ transplants performed in Spain. Therefore, transplantation must not be considered as a luxury for rich countries, but as a cost-effective therapy able to save many lives all over the world.
Some regions of Northern Italy, where the model has been applied, are now reaching over 30 donors PMP. Similar increases have been reached in Latin America and elsewhere. If the right conditions exist the Spanish model can be replicated resulting in a positive change in organ donation rates.