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Howard Nathan - USA - Monday 28 - Management and organization models for donation and transplantation A challenge for healthcare systems
 

Howard Nathan - USA - Monday 28 - Management and organization models for donation and transplantation A challenge for healthcare systems

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  • Revise to focus on system readiness for breakthrough performance through integration/ collaborationWe know the current system does not sufficiently serve the needs of Canadian patients. The Canadian public has expressed a strong expectation of higher performance in both the organ and the tissue donation and transplantation systems. Build trust equity with Canadians at a time when their faith in our healthcare system is at historic lows, by bringing more timely and equitable access to patients requiring both organs and tissuesBecause of all we have delivered—metrics, the LDPE, engagement, the process—we have brought a disparate community together. That community is engaged and ready to make change—there is a swell of momentum…what we have contributed to the community has given them the ability/capacity to move forward.There is ample evidence that the key to significant performance improvement is collaboration and shared accountability—it is what sets leading systems apart.Build on the momentum that has been developed through the consultation process and engage in a good news story where governments are leaders of change and builders of bridges.Canadian Blood Services has demonstrated its ability to lead a transformational change agenda, first in the blood system and now in OTDT through its efforts in registries and in the development of the strategy moving forward. It is now time for all decision makers to act collectively, to ensure Canadians have the organ and tissue systems they deserve.

Howard Nathan - USA - Monday 28 - Management and organization models for donation and transplantation A challenge for healthcare systems Howard Nathan - USA - Monday 28 - Management and organization models for donation and transplantation A challenge for healthcare systems Presentation Transcript

  • Management and Organizational Models for Donation and Transplantation: A Challenge for Healthcare Systems – North America Presented by: Howard M. Nathan President and CEO Gift of Life Donor Program Philadelphia, PA, USA
  • Gift of Life Donor Program Philadelphia, USA
  • Gift of Life Donor Program Philadelphia, Pennsylvania USA • Non-Profit OPO/Tissue Recovery/Eye Bank • Established in 1974 • Federally designated OPO (by Medicare) for eastern PA, Southern NJ & Delaware - 130 Acute Care Hospitals - 15 Transplant Centers, 43 Programs - 10.3 Million Population • 2011* Projected Data: - 440 Organ Donors / 43 Donors/MM - 1,236 Bone Donors and 2,551 Cornea Donors • Over 32,000 organs for transplantation and over 375,000 tissue allografts • Accredited by: Association of Organ Procurement Organizations (AOPO); American Assoc. of Tissue Banks (AATB) & Eye Bank Assoc. of America (EBAA); UNOS/OPTN member OPO*Source: Gift of Life data. 2011 Projection Based on YTD performance through 11/15/2011
  • The U.S. Federal Government’s Role in Donation and Transplantation Department of Health and Human Services (DHHS) Advisory Committee on Transplantation (ACOT) Centers for Medicare & Other Agencies Health Resources and Services Medicaid Services Administration (HRSA) (CMS) Healthcare Systems Bureau (HSB) Division of Transplantation (DOT) OPTN Contractor SR Contractor CWBYCTP (UNOS)Slide Courtesy of Charlie Alexander, UNOS
  • Organ Procurement and Transplantation Network (OPTN)• Federal law mandates that all U.S. transplant centers and organ procurement organizations (OPOs) be members of the Organ Procurement and Transplantation Network (OPTN) to receive any funds through Medicare• United Network for Organ Sharing (UNOS), based in Richmond, Virginia, administers the OPTN under contract with the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS)
  • U.S. Organ Donation & Transplantation Structure• 58 Organ Procurement Organizations (OPOs)• 252 Transplant Centers (Hospitals) – 800+ organ programs (kidney, heart, liver, lung, pancreas, intestine)• United Network for Organ Sharing (UNOS) – OPTN Contractor• U.S. Donation & Transplantation Statistics (2010): – Deceased Organ Donors = 7,943 (DCD Donors = 941) – Living Organ Donors = 6,559 – U.S. Total Transplants Performed – 31,160 • Deceased Donor Transplants = 24,601 • Living Donor Transplants = 6,559Source:UNOS
  • Board of Directors: 41 elected members with no more than 50% transplant professionals; meets quarterly.United Network 16+ committees (e.g. organ specific, ethics, patients, OPO, etc.) For Organ Each of 11 regions represented By Councilor Sharing All allocation policies developed by UNOS are subject to final approval by the Secretary of DHHS.In 1987, the DHHS (federal government) contracted with UNOS to operate the OPTN (organ procurement and transplantation network)
  • What UNOS Does• Oversees national database of clinical transplant information and operates computerized organ sharing system since 1986• Manages Wait List - establishes candidate wait list criteria• Facilitates organ matching – Matches donated organs to patients via 24-hour Organ Center• Establishes allocation policies for all deceased donor organs• Establishes criteria for transplant centers and approvals• Maintains data on all donors and transplants (LIVING & DECEASED) and audits OPOs and Transplant Centers• Supports OPOs by assisting in educating national healthcare associations and societies
  • UNOS Regional MapOrgan allocation policies are “local” (OPO), then regionalthen national – and are patient specific (not transplant center)
  • U.S. National Data Waiting List vs. Transplant Recipients 130,000 WAITING TRANSPLANTED 120,000 110.225 110,000 100,000 90,000 80,000 70,000 60,000 37,291 50,000 40,000 30,000 20,000 15,208 24,601 10,000 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 199 199 199 199 199 199 200 200 200 200 200 200 200 200 200 200 201Source: Based on OPTN data as of March 11, 2011 with transplant data available through December 31, 2010 .Waiting list data as of December 31, 2010. Count is based upon registrations.
  • United States Waiting List Total Candidates November 2011* 90,368 Kidney 16,264 Liver 3,171 Heart 1,733 Lung 2,118 Kidney/Pancreas 1,345 Pancreas 72 Heart/Lung 263 Intestine 112, 674 TOTAL WAITINGSource: UNOS as of November 23, 2011
  • U. S. National Trends in Organ Donation Living vs. Deceased Organ Donors 2010 1995 – 2010 8,500 Deceased 8,024 8,085 7,990 8,021 8,000 Organ Donors 7,593 7,943 7,500 7,153 7,943 7,000 6,895 6,618 6,814 6,965 6,731 6,610 6,560 6,500 6,559 5,873 6,455 6,313 6,218 Living 6,000 5,985 6,080 6,187 5,794 5,824 Organ Donors 5,500 5,362 5,416 5,478 5,001 5,000 6,559 4,557 4,500 4,052 4,000 3,781 Waiting List 3,500 3,488 Deaths 3,000 6,176 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Living Donors Deceased DonorsSource: Based on OPTN data as of March 11, 2011 with donor / wait list removal data available through December 31, 2010.Count based on candidates. Candidates - A patient who is waiting at more than one center, or for multiple organs, is counted as onlyone candidate. Totals may be less than the sums due to patients included in multiple categories.
  • U.S. National Organ Donor Experience 1995 – 2010 Total Donors = 201,001 LD (n=93,340) BD (n=101,443) DCDs (n=6,218) 564 644 920 14,000 393 791 848 941 168 189 268 13,000NUMBER OF ORGAN DONORS 12,000 117 11,000 87 75 6,757 7,029 7,375 10,000 6,189 7,294 7,102 7,002 71 78 5,912 6,001 7,142 64 9,000 5,868 8,000 5,737 5,718 7,000 5,401 5,347 6,000 5,299 5,000 4,000 6,619 6,630 6,828 7,004 6,902 6,732 6,609 6,559 3,000 5,945 6,315 6,218 4,570 5,045 2,000 3,496 3,802 4,066 1,000 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 YEAR*Source: Based on OPTN data as of March 17, 2001 with data through December 31, 2010.
  • US Deceased Organ Donation Summary 1 Jan 2010 – 31 December 2010 Population (Millions) Donors Per Mill Population Transplants Per Million Population400350 307300250200150 83.1100 26.6 50 0 POPULATION DONORS /MM TRANSPLANTS /MM (MILLIONS)
  • Organ Donation In the U.S.• Each OPO has geographical service area designated by the Federal Government for recovering organs in all hospitals in that region• OPO designation carried out by the Centers for Medicare and Medicaid Services (CMS), based on organ recoveries and organ transplants performed• OPOs required to be a member of the national Organ Procurement and Transplantation Network (OPTN)
  • 58 OPO Donation Service Areas in the U.S. 307 million people – 7,944 deceased donors (2010) OPO Data Population Bases from 1.2 Million to 18.9 Million Deceased Donors Recovered ranged from 32 to 439 DonorsDonors per million (dpm) ranged from 17 to 44 DPM: 26.5 mean
  • A Donate Life Organization
  • Pennsylvania Act 102 - 1994 State Routine Referral Law Hospital Requirements• Routine Referral of all patient deaths to OPO• Consent requests restricted to OPO staff or “designated requestors”• Medical record reviews to monitor compliance• $ 500 fine for each instance of non-compliance
  • Revised HospitalConditions of Participation For HospitalsReceiving Medicare Funding Guidelines published: June 22, 1998 Effective date: August 21, 1998
  • U.S. Secretary of Health Challenges Community to Increase Donation and Transplantation• Increase the number of deceased organ donors (2003) GOAL: 75% conversion rate• Increase the average number of U.S. Department of Health organs transplanted per deceased and Human Services Secretary Tommy Thompson donor (2004) announced in April 2003 GOAL: 3.75 organs/donor• Increase DCDs to 10 % of all
  • U.S. Hospital and OPO Requirements and Collaborative Goals • Routine Referral of All Deaths • Conversion Rate = 75% • Organs Transplanted per Donor = 3.75 • Implementation of Donation After Cardiac Death (DCD) Policy
  • Where the RubberMeets the Road….Conversion RateTotal number of organ donorsdivided by the total number ofpotential (eligible) donors,shown as a percent
  • Understanding PerspectivesOPO Interest Care Team PerspectiveOrgan referral Failure & lossOn-site; early linkage Family betrayalOptimize organ function Caring for dead patientBrain death pronouncement Time, resources: futile careCollaborative request Loss of controlCompliance Dictated practice
  • Organ Transplantation Breakthrough Collaborative, identified “breakthrough”best practices that are associatedwith increases in transplantation.
  • OPOs Effective Relationships & Best Practices Donor TransplantHospitals Centers
  • 90,000 80,000 70,000 Number of Registrations 60,000 50,000 40,000 30,000 20,000 10,000 0 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 199 199 199 199 199 199 199 200 200 200 200 200 200 200 200 200 200 201 Kidney LiverSource: Based on OPTN data as of May 23, 2011 with data through December 31, 2010. Count based upon candidates.Candidates - A patient who is waiting at more than one center, or for multiple organs, would be counted as only one candidate.
  • 5,000Number of Candidates 4,000 3,000 2,000 1,000 0 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 20 20 20 Heart Lung Pancreas Heart-Lung Kidney-PancreasSource: Based on OPTN data as of May 23, 2011 with data through December 31, 2010. Count based upon candidates.Candidates - A patient who is waiting at more than one center, or for multiple organs, would be counted as only one candidate.
  • US Deceased Donors by Donor Type: 1996-2009 9000 8000 7000 6000 5000 DCD 4000 ECD 3000 SCD Increase in Donors 1996 -2009: 2000 SCD 17%, ECD 102%, DCD 1196% 1000 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Source: UNOS, based on OPTN data as of July 23, 2010
  • Kidney Transplants in the U.S. (Living & Deceased Donors) 1999 – 2010 11,500 10,622 10,661 10,591 10,500 10,553 10,442 9,913 9,500 9,359 8,539 8,668 8,500 8,126 8,234 8,044 7,500 6,647 6,570 6,500 6,434 6,387 6,470 6,240 6,043 5,968 6,277 6,042 5,500 5,495 4,721 4,500 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Deceased Donor Tx (113,752) Living Donor Tx (73,294)Source: Based on OPTN data as of November 23, 2011 with data through December 31, 2010.
  • Liver Transplants in the U.S. (Living & Deceased Donors) 1999 – 2010 7,000 6,363 6,228 6,101 6,000 5,848 6,121 6,070 6,009 5,351 5,000 4,969 4,595 4,671 4,499 4,000 3,000 2,000 1,000 524 406 363 323 323 322 288 219 282 257 266 249 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Deceased Donor Tx (66,825) Living Donor Tx (3,822)Source: Based on OPTN data as of November 23, 2011 with data through December 31, 2010.
  • Organ Transplants in the U.S. 1999 – 2010 1,000 941 915 903 924 891 906 871 881 864 854 828 837 603 555 542 500 504 473 466 468 439 436 378 359 350 198 185 180 178 175 152 151 113 107 116 73 82 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Kidney Pancreas Pancreas IntestineSource: Based on OPTN data as of November 23, 2011 with data through December 31, 2010.
  • Organ Transplants in the U.S. 1999 – 2010 2,500 2,333 2,199 2,202 2,211 2,188 2,155 2,125 2,193 2,209 2,057 2,163 2,015 2,000 1,770 1,660 1,500 1,478 1,468 1,406 1,405 1,172 1,085 1,000 1,059 1,042 959 893 500 51 48 31 31 27 33 29 40 35 30 41 27 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Heart Lung Heart/LungSource: Based on OPTN data as of November 23, 2011 with data through December 31, 2010.
  • Push and Pull in Organ Donation and Transplantation - ChallengesOPO Push Transplant Center PullRecover as many organs CMS quality review as possible means actual vs. expected increased: outcomes ECDs if lower than expected DCDs - center citedHigher Kidney Discards Results in ConservativeOrgan Allocation policy organ selection limitations (no older Increase living donation donors for older recipts) with paired donation
  • Population (million inhabitants): 34.1Deceased Organ Donors, incl 495 (14.5)DCD (pmp)Deceased Donor Kidney TX (pmp) 749 (22.0)Living Kidney TX (pmp) 485 (14.2)Liver TX (pmp) 451 (13.2)Heart TX -incl Ht-Lu TX - (pmp) 170 (5.0)Heart-Lung TX (pmp) 2 (0.1)Lung TX (pmp) 180 (5.3)Pancreas TX (pmp) 73 (2.1)Small Bowel TX (pmp) 1 (0.0) Source: Newsletter Transplant , Volume 16, No 1; September 2011.
  • ORGAN AND TISSUE DONATION AND TRANSPLANTATION SYSTEM• Principles of the Canada Health Act: – Public administration, comprehensiveness, universality portability and accessibility• The Canada Health Act establishes the criteria and conditions related to insured health care services - the national standards - that the provinces and territories must meet in order to receive the full federal cash transfer contribution. (Government of Canada, 2007, www.hc-sc.gc.ca)• The provinces of Canada are constitutionally responsible for the administration and delivery of health care services.• In June 2005, the Supreme Court struck down a Quebec law that prohibited people from buying private health insurance to cover procedures already offered by the public system.
  • ORGAN PROCUREMENT PROGRAMS 10 Provincial OPO’s
  • TRANSPLANT PROGRAMS 2009 Statistics* 2,155 organs transplanted • 1,208 kidneys • 458 livers • 168 hearts • 184 lungs 3,796 on waitlists • 316 withdrew from lists • 249 died while waiting 487 deceased organ donors *CORR e-statistics
  • Transplants, Canada, 1996-2009 (pmp) 80.0 70.0 68.3 64.9 63.9 61.3 61.5 60.0 56.8 57.5 57.0 56.9 58.5 53.8 53.8 55.5 52.8 50.0 40.0 30.0 20.0 10.0 0.0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009Source: Canadian Organ Replacement Register, Canadian Institute for Health Information (2010)
  • Deceased Donor Kidney Transplant Rates in Canada Provincial Comparisons (2007-2009) Kidney Transplants (Deceased Donor only) PMP35.030.025.020.015.010.0 5.0 0.0 Canada BC AB SK MB ON QC ATL 2007 2008 2009 Source: Canada: CORR e-statistics Note: not possible to compare for other organs as not every province transplants all organs
  • Canada 2010:Total-468 DCD-44 (9.4%)Slide courtesy of Frank Markel, Trillium Gift of Life Network
  • All Organ Recipients from DCD Donors Trillium Gift of Life, Ontario June 2006 – Dec 31, 2010 123 donors, 36(22%) no donation ORGAN NUMBER Kidney left 116 Kidney right 109 Kidney both 1 Liver 50 Lung left 5 Lung right 2 Lung Bilateral 18 Pancreas 2 Islets 1 Total # Transplants 304Slide courtesy of Frank Markel, Trillium Gift of Life Network
  • Lessons Learned RE: DCD • DCD has been the single largest driver of kidney transplant activity in Ontario (17% for the last 3 years), 226 additional kidney txps in 4 1/2 years • While there is potential for improvement in NDD, both demographics and critical care management will reduce potential eligible NDD donors • In Ontario we are being more conservative regarding acceptance of DCD donors ( reduce age from 70 to 65yrs) and some programs are even more limitedSlide courtesy of Frank Markel, Trillium Gift of Life Network
  • CBS MANDATEIn April 2008, the FPT governments (except Québec) gave Canadian BloodServices a mandate for organ and tissue donation and transplantation:Activities of the former Canadian Council for Donation and Transplantation (CCDT),including advice to FPT Ministers of Health on matters related to OTDT; • Development of leading practices, public awareness and professional education; • System performance; • Patient Registries: Living Donor Paired Exchange, National Organ Waitlist, Highly-Sensitized Patients, and other related databases; and, • Development of a coordinated strategic plan for OTDT 45
  • ORGAN DONATION AND TRANSPLANTATION SYSTEM TRANSFORMATION TODAY FUTURE SYSTEM A professional option, limited A professional obligation, routine Organ Donation in accountability for performance, and end-of-life care and support for Canadian Hospitals unrealized donation potential 50% more transplantsWide variation in referral criteria, waitlist Canadians with Consistent policies andmanagement, allocation rules and wait End-Stage Organ standards, transparent allocation rules times Failure and fairer access to transplantation No consistent approach to Mandatory reporting and accountability; few if any Accountability transparency of compliance consequences for poor performance and performance Lack of sustained, systematic efforts Dedicated, evidence-based, Performance to improve overall Canadian methodology-driven performance and Management performance strategy management Single waitlist with automated matching Limited, high-level data integration to Information and offer management; integrated data support analysis; manual offer Systems and Data management and analytics to supportmanagement and urgent status wait list performance management
  • THE SYSTEM IS READY FOR CHANGE… The organ and tissue communities are ready — there is the will, the capacity and the commitment—the momentum is there now Canadian Blood Services is ready — for the first time, the organ and tissue communities have identified a leader to facilitate change Breakthrough performance is possible — with collaboration and shared accountability between provinces, programs and institutions47
  • Thank You!Andrea Reynolds, Gift of LifeCharlie Alexander, UNOS Past PresidentKim Young, Canadian Blood ServicesCorrespondence: hnathan@donors1.org
  • Gracias!