Spanish transplant model would save 20 000 lives a year in EU
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1758 (Published 29 March 2010) Cite this as: BMJ 2010;340:c1758All rapid responses
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Why do the transplant lobby persist in quoting the rates of organ
donation in "numbers of organ donors per million of the population"?
Surely we should be talking about the numbers of organ donors per 1000 of
brain dead patients in intensive care! Or - if we are considering donation
after cardiac death - the number of organ donors per 1000 of potential
organ donors who are having their intensive therapy withdrawn and who die
within the hour! This has nothing to do with the population of a country -
it has everything to do with laws related to drink driving, the use of
seat belts, the state of the roads, gun law, violent crime, and the
excellence or otherwise of the emergency services! It has to do with the
availability of ICU beds, other resources provided for the care of the
critically ill and the quality of the intensive care delivered. Obviously
if you manage a severe head injury effectively you will reduce your pool
of donors. Maybe Spain has a problem!
Yet again the tranplant lobby attempt to blame intensive care
specialists for not identifying potential organ donors. Having worked in
the UK and Australia, both of which have relatively "low organ donation
rates per million of the population" I know this is rubbish! Clearly we
have a problem if the conversion of potential to actual donors is only 50%
(as it is in the UK and Australia) but this is more likely related to a
vibrant multicultural richness not seen in catholic Spain!
I feel sympathy for my intensive care colleagues in Romenia and
Bulgaria being on the receiving end of a Europen directive devoid of sense
and irrelevant to their medical context.
Competing interests:
None declared
Competing interests: No competing interests
The success of the Spanish Model of transplantation needs to
be lauded but rapid implementation of such a model globally,
without an extensive research can be counterproductive. First
of all the manpower involved may raise the cost factor.
Secondly, the ethics of transplantation may be compromised in
the developing nations, where the want of money may lead to
corrupt practices in veil of presumed consent. Also a sudden
change in practice may not be welcomed by the health
practitioners and lead to failure.
The Spanish transplant model should be aggressively advertised
in media before implementation in UK to garner massive public
support and minimize risk of any failure.
Hemant Sharma
SpR Vascular Surgery
Arrowe Park Hospital, Wirral CH49 5PG
Competing interests:
None declared
Competing interests: No competing interests
Spanish transplant model: a half-truth?
In the On-Line Merriam-Webster Dictionary, a “half-truth” is defined
as follows:
1 : a statement that is only partially true
2 : a statement that mingles truth and falsehood with deliberate
intent to deceive (1)
This response is written taking only the first definition into
account.
In the article signed by García Rada on the Spanish transplant model
(2), two sentences are especially noteworthy:
The first concerns what Ms. Trinidad Jiménez said: Ms. Jiménez told
the conference: "If the donation rates throughout the EU . . . rise to
those of countries with the highest figures, 20,000 lives a year would be
saved."
The second concerns what Mr. Rafael Matesanz, director of Spain’s
National Transplant Organisation, said: The "Spanish model" is a voluntary
donation system that is based on altruism. He told the BMJ that its
success was based on effective training of hospital transplant
coordinators, optimising detection of potential donors, and an integrated
system that is coordinated at three levels: nationally, regionally, and by
hospital.
In neither of these two statements was any reference made to the
hugely important economic aspects of transplants.
At the beginning of March 2010, a meeting of transplant patients was
held at “La Fe” hospital in Valencia (Spain).
In one of the sessions, the Head of the Pharmacy service stressed the
importance of the appropriate use of pharmacotherapy for these kinds of
patient who are subject to very complex treatments, in order to prevent
organ rejection.
The head of the service stated that the expenditure on medicines for
these patients “amounted to 10% of the hospital’s overall expenditure”.
The main drugs prescribed are antifungal, antiviral and immunosuppressant
drugs (3).
This is one of the economic aspects of the Spanish Model that should
also be recognised.
It is true that saving life has no price, but when one considers
distributive justice and the sustainability of health systems, it is
absolutely essential to know the cost of each one of these 20,000 lives a
year that would be saved.
The second aspect that should be mentioned is the cost to the health
system of the special payments to organ transplant activity.
These costs are incurred at two stages of the process: the locating
of possible donors and the effective undertaking of the transplants.
These are referred to in a study carried out in the Autonomous Region
of Navarra (4), which more or less reflects the situation throughout
Spain.
In that region there is a tissue donor detection team that operates
24 hours a day throughout the year.
In 2006 the Regional Government established a protocol for economic
compensation distribution aimed at providing incentives to this activity.
The amounts involved are:
– Per “potential” tissue donor: 96.16 euros.
– Per extracted cornea / sclera: 147.25 euros.
– Per extracted heart valve / great vessels: 306.52 euros.
– Per “spongy” bone extraction: 96.16 euros.
– Per “cortical” bone extraction: 581.78 euros.
– Per multi-organ donor detection: 1,190 euros.
These amounts are distributed by percentage among the people who may
have contributed to the detection to each of the possible donors.
There is a synoptic table reflecting this distribution in the above
mentioned study.
This first aspect refers to the detection of possible donors.
The surgical activity involved in transplants is, in the strictest
sense, that undertaken in duly accredited hospitals (kidney, heart, lungs,
liver, pancreas, etc.) and there is an economic cost to the operations
undertaken by the professionals working there.
In Spain, as a result of being geographically distributed into
Regional Autonomies, there is a disparity in the payments made to those
health professionals. For this reason, exact figures cannot be provided on
the amounts involved in this activity.
However, simplifying this situation, it may be stated that if a non-
transplanting surgeon annually receives a payment of N euros, then a
transplanting surgeon may receive (N x 1.5, N x 2,…) euros depending on
the number of transplants in which he/she has been involved.
Naturally, similar reasoning has to be applied to all the other
health staff involved in this activity.
Is the economic incentive important for the success of the Spanish
model?
A news article appeared in February 2009 (5) under the following
headline: “Bad-feeling among surgical transplant staff. Loss of incentives
angers transplant specialists.”
The main body of the article said “Yesterday Doctor González-Pinto
stated that the abolition of incentives is in itself harmful as it may
contribute to demotivating teams”.
This now is the full Spanish model:
1. Altruism of Spanish donors.
2. Repercussion on pharmaceutical expenditure.
3. Extra economic payment to the professionals involved.
Having said all that, we declare that we are whole-organ donors.
We declare that we have no conflict of interest
REFERENCES
1. http://www.merriam-webster.com/dictionary/half-truth (accesed on
13.04.2010)
2. BMJ 2010;340:c1758
3. http://www.levante-emv.com/salud-vida/2010/03/02/trasplantados-
consumen-10-farmacos/683632.html (accesed on 14.04.2010)
4. MARAVI-POMA, E. et al. Coordinación y logística del trasplante de
tejidos de donantes de cadáver intra y extra-hospitalarios. "Modelo
Pamplona": Cadena de actuación 1992-2006. Anales Sis San Navarra [online].
2006, vol.29, suppl.2 http://scielo.isciii.es/scielo.php?pid=S1137-
66272006000400006&script=sci_arttext (accesed on 14.04.2010)
5. http://www.lavozdeasturias.es/noticias/noticia.asp?pkid=474767
(accesed on 14.04.2010)
Competing interests:
None declared
Competing interests: No competing interests