Organ procurement and renal transplants in Spain: the impact of transplant coordination

The growing shortage of cadaveric organ donors remains the majorobstacle to achieve satisfactory rates of transplantation. InSpain an integrated transplant organization programme, mainlyfocusing on organ procurement, has been established, based ona network of well-trained transplant coordinators. In everyhospital that was a potential candidate for donor procurement,a transplant coordinating team was founded, including medicaldoctors and nurses (42% of whom belonged to renal units). Theteam was put in charge of all steps of transplant procurement,from locating potential donors to the organ grafting or tissuebanking. The teams were integrated into a National Organizationof Transplants (ONT), i.e. a coordinating structure withoutexecutive function. The annual rate of cadaveric organ donors increased from 14.3per million population (p.m.p.) in 1989 to 21.7 donors p.m.p.in 1992. Total solid organ retrieval rate increased by 81% andrenal transplants by 44% during the same period (from 1039 to1492, i.e. from 26 to 38.8 renal transplants per million population,99% of which were kidneys from cadaveric donors). This successful approach has overcome obstacles such as untrainedor undertrained staff, failure to identify donors, or reluctanceto approach grieving families.     

Activity of transplant coordination in Uruguay

The purpose of this study was to analyze the evolution of donation and organ transplantation in Uruguay, after the initiation of a program of transplant coordination, which began in 2000. The total number of effective donors increased from 28.7 per million people (pmp) in 2000 to 48.1 pmp in 2005, which constituted an increase of 75%. The number of real donors also increased from 10 pmp in 2000 to 20.6 pmp in 2005, more than a 100% increase, with a cadaveric renal transplantation rate of 36 pmp (2005). The conversion of effective to real donors (RD/ED) increased from 0.125 to 0.42. Familial refusal decreased from 62.1% in 2000 to 19% in 2005, which constituted a decrease of 70%. We concluded that implementation of transplant coordinators and involvement of intensive care medical doctors in coordination have had a strong impact on these results.     

Chronological evolution of the renal transplant in Spain

IntroductionWe try to establish the chronological evolution that has taken the renal transplant in Spain. Supported on the heuristic one we gather from the first experiences and scientific works published at the beginning of the sixties up to those of the finals of the XXth century in which the procedure is already consolidated.Material and methodWe check the Spanish bibliography urology, the publications of renal transplant, those of dialysis and the nefrology and all the bibliographical references we have located beside contributing our personal experience.ResultsThe zeal to help the patients in renal terminal insufficiency was the engine that stimulated the Spanish urologist to begin with the practice of the renal transplants. In May, (1960) the Dr. Martínez-Piñeiro carries out the first one, without satisfactory result and is in july, (1965) when the team of the Dr. Gil-Vernet realizes a transplant of corpse with long billiard cue sobrevida of the patient and of the organ. With the advances in the treatments immunosuppressants, the procedure is consolidated as the best option for the renal insufficiency treatment and the Spain principal hospitals add to the transplants.ConclusionsThe Spanish urologist, with their effort, dedication and confidence in the results of the technology, are the beginning and principal persons in charge of the surgical activity of the implant and only when the benefit was evident the Administration moved to establishing the procedure for its development; after the constitution of the ONT, with its unfolding of means, they achieves that Spain reaches and guarantees a world primacy so much in number of donors as of implants.     

Domino liver transplant: influence on the number of donors and transplant coordination

The shortage of organs forces coordinators to seek new forms of generating organs for transplantation of the increasing numbers of patients on waiting lists. A recent technique called sequential transplant or domino liver transplant (DLT) allows the transplantation of a patient with chronic liver disease by implantation of a full-size liver derived from a patient with familial amyloidosis polyneuropathy (FAP) who receives a cadaveric graft. Therefore, it is possible to transplant two patients with only one cadaveric liver. The present report illustrates the use of this technique for the first time in our country, thereby increasing the number of hepatic transplants by 25%.     

The DRG hospital payment system, surgical readmissions and cost containment

We analyzed all adult surgical patients requiring readmission to the surgical service of an acute care academic hospital for a four-year period (1/1/85-12/31/88). We stratified surgical readmissions by the number of times the patient was readmitted to surgery (from one to five times). For surgical patients 41.1 per cent of the readmission population was readmitted more than once, only 4.4 per cent were readmitted five or more times. Patients requiring three or more admissions generally had the greatest hospital resource utilization, financial risk under DRG payment, and mortality, compared with other surgical readmissions. This analysis suggests that within the surgical readmission population resource parameters may differ by the number of readmissions per patient. Factors were identified which corresponded to a greater likelihood of surgical readmission, and possibly allow the focus of outpatient services which may reduce hospital inpatient costs in the future.     

Educational curriculum and organization in the general hospital

With sufficient organization and personal activity comprehensive postgraduate medical education can successfully be carried out even at a small surgical department, especially--but not exclusively--in one's early years of postgraduate education and especially if external course offers are made use of. Postgraduate education is endangered not so much because of local circumstances, but because of external influences like official regulations on working-time, the lack of offers for rotations, and restrictions on our duty to take professional care of people.     

Importance of informatics and database management in transplant coordination

Advanced use of informatics within modern health care has become essential. Transplantation and transplant coordination, a high technically advanced and very specific niche within health care, is strongly depending on time management and exclusion of possible pitfalls within an acute organization at both the donor and the recipient sites. Based on the increased donor and transplant activity, we stratified two goals. The first goal was to improve working methods at the donor site. The second goal was to reduce administrative tasks and increase quality follow-up at the recipient side. For the donor process, we designed a Donor Database, that was created for donor registration and quality data reporting. A 24/24 h accessible website was created and was linked with clinical pathways and reports. For the liver transplant process, we built another database system in FileMaker pro, creating a quality follow-up and reporting methods. Based on a retrospective analysis and review of two executive time periods, we saw a clear improvement in the donor reporting method, and the quality of the procedure. Possible mistakes within the acute organization were easily detected based on clinical pathways provided by the website on one hand, and integrated within the database system on the other hand. We succeeded in bringing high-quality informatics to the floor of donor and transplant procedures and follow-up. Retrospective analysis showed a definite improvement, with a positive impact on data reporting, time management and administrative follow-up.     

The required coordination of pancreas-islet-kidney transplantation in Spain

We describe the historical background and current situation of pancreatic and islet cell transplantations in Spain and other countries, as well as their relationship with replacement therapy in chronic renal failure in diabetic kidney transplant recipients. Emphasis is placed on the improved results achieved in the last decade, the increased demand for these techniques and the need for highly efficient organization of these transplantations to optimize the available resources, which are clearly limited in terms of both donation and finances. The process initiated by the National Transplantation Organization (NTO) to coordinate all these activities and the preparation of a consensus document endorsed by all the professional bodies involved is described.     

Introduction of the certificate in transplant coordination in the United Kingdom

Training for transplant coordinators is not mandatory in the United Kingdom, although the United Kingdom Transplant Coordinators Association has provided informal courses since 1988. The authors of this article were responsible for the development of an accredited training program for transplant coordinators in the United Kingdom. Accredited by the University of Central England, the course modules have been run and managed by the Association since 1996. The course consists of 3 modules: Introduction to Transplant Coordination; Interpersonal and Professional Skills for Transplant Coordinators, and Introduction to Research Methods for Transplant Coordinators. Between 1996 and 1999, 64 transplant coordinators (60% of transplant coordinators currently in post) in the United Kingdom have undertaken at least 1 module. The Association feels that the accredited training program means one step further on the road to professional recognition of transplant coordinators in the United Kingdom.     

Attitude toward living liver donation in transplant hospitals in Spain, Mexico and Cuba

Background

Transplantation hospitals have played a key role in developing deceased organ donation and transplantation (ODT). To reduce the number of deaths on the transplant waiting list, it is essential to encourage living liver donation (LLD). Involvement of personnel in these hospitals is crucial.

Purpose

We analyzed the attitudes toward LLD among hospital personnel in Spain, Mexico, and Cuba.

Materials and methods

Data were obtained from 5 transplant hospitals in Spain, Mexico, and Cuba. The sample was stratified according to job category and type of service (n = 2273). A validated questionnaire about living donation was used as the instrument.

Results

Most respondents (82%) were in favor of related LLD. If the LLD was not related, acceptance fell to 21%. A total of 85% of physicians, 79% of nursing personnel, 74% of nursing assistants, and 83% of auxiliary staff were in favor (p < .001). A favorable attitude toward LLD was associated (P < .05) with age (37 ± 10 y vs 39 ± 10 y), a favorable attitude toward deceased donation, a belief that a possible transplant is needed, acceptance of LLD if necessary, a favorable attitude toward living kidney donation, family discussion about ODT, a partner's favorable attitude toward ODT, an intention to participate in prosocial activities, being a Catholic, and a belief that one's religion is in favor of ODT.

Conclusions

Personnel from Spanish, Mexican, and Cuban transplantation hospitals have favorable attitudes toward LLD. This suggests that there may be an increase in LLD in the future, provided that there is the necessary sociopolitical and economic support.     

Economies of scale, physician volume for neurosurgery patients, and the diagnosis-related group prospective hospital payment system

Hospitals face an increasingly competitive environment in the era of diagnostic related group (DRG) prospective pricing. Further reductions in Medicare outlays relative to hospital costs are likely, given the looming federal deficit. We analyzed the relationship of individual neurosurgical volume, hospital costs, and outcome. All neurosurgical patients (n = 1002) treated for a 3-year period at our large academic medical center were grouped into those treated by low-volume neurosurgeons versus those treated by high-volume neurosurgeons (arbitrarily defined by us); 95% of patients admitted for neurosurgical procedures fit into one of these two categories. Patients of low-volume neurosurgeons had higher hospital costs (even after correction for DRG case-mix and severity of illness) (P less than 0.01), a much worse financial position under DRGs (P less than 0.01), but a similar outcome for both emergency and nonemergency admissions when compared to patients of higher volume neurosurgeons. Pearson correlation showed an inverse relationship between declining cost per patient and increasing neurosurgical volume for both nonemergency patients -0.340 (P less than 0.0001), and emergency patients, -0.321 (P less than 0.0001). These findings suggest that the volume of neurosurgical procedures performed by an individual neurosurgeon is related to hospital resource utilization. This study also suggests that the DRG prospective payment system could provide incentives that may affect both neurosurgical practice and the access to neurosurgical care.     

Economies of scale, physician volume for urology patients, and DRG prospective hospital payment system

Diagnosis Related Group (DRG) hospital payment has begun to squeeze hospitals financially and is likely to do so in the future. This study analyzed the relationship between the volume of urologic procedures by an individual urologist, hospital costs per patient, and outcome. We used a three-year DRG database of urology patients (N = 2,980) at an academic medical center to analyze these. Low-volume urologists (arbitrarily defined by us) had higher hospital costs per patient, financial losses versus profits under DRGs, and a poorer outcome when compared with high-volume urologists. Pearson correlation showed a positive relationship between cost per patient and physician volume for nonemergency patients (-0.129, p less than 0.0001) and emergency patients (-0.368, p less than 0.0001). This may have been explained (in part) by a greater severity of illness for patients of low-volume urologists. These findings suggest, however, that the volume of urologic procedures per urologist may be related to hospital resource consumption. The health care financing environment of the future should provide substantial interest in this finding for those involved in the consumption of urologic services.     

Psychosocial profile of patients on the liver transplant list

INTRODUCTION: Researchers have shown that psychosocial factors influence adherence to treatment and, consequently, prognosis. Psychosocial assessment during the preoperative outpatient phase has allowed physicians to make better treatment decisions. OBJECTIVES: We sought to describe the psychosocial profile of patients on the liver transplant list referred for psychological assessment. METHOD: We reviewed all files of patients referred for pretransplant psychological assessment over a 14-month period. RESULTS: The sample included 73 patients: mean age 49.46 +/- 11.18 years and; mean formal schooling 7.35 +/- 4.65 years. Of those, 56.1% reported a cognitive complaint; 33%, symptoms of anxiety, and 17%, depression. Of the sample, 45.8% were referred for alcohol use, and 37.5% for mood changes. During the assessment, 15.9%, 34.4%, and 1.6%, of patients reported using alcohol, tobacco, or some other type of drug, respectively. Of patients, 53.6% reported having used alcohol at some point in their life-26% tobacco and 10.9% some other type of drug. After the assessment, the main referrals were 35.6% to family counseling, 32.1% to cognitive assessment, and 28.5% to psychological counseling. CONCLUSION: This study highlighted the prevalence of cognitive complaints and current/previous use of chemical substances. These findings were identified through psychological inquiry, which was able to direct the individual treatments. Although these conditions prevailed among this population, their early detection allowed for early intervention to improve adherence and minimize possible intervening problems.