Study Finds Wide Variation in Organ Procurement Performance

Addressing the wide variation in the performance of organ procurement organizations (OPOs), particularly at individual hospitals, could help to increase the organ supply, according to a retrospective cross-sectional study.

Of 931 potential organ donors identified at 13 hospitals covered by two OPOs, only 242 donors, or 26%, actually had organs recovered, reported Seth Karp, MD, of Vanderbilt University Medical Center in Nashville, Tennessee, and colleagues.

For each hospital, the ratio of actual donors to potential donors varied widely, from 0.0 to 0.51. Of the two OPOs analyzed, one recovered 14% of possible donors, while the other recovered 48% (rate ratio [RR] 2.77, 95% CI 2.56-2.99, P<0.001), they noted in JAMA Surgery.

Of note, hospitals where transplants are performed (two of the 13) had a higher probability of donor recovery compared with non-transplant hospitals (OR 5.0, 95% CI 3.09-8.45, P<0.001).

"There are many, many donors out there that are not being picked up by the system," Karp told MedPage Today, "and it's due to a failure of regulation at the government level, and due to a failure of the performance of the OPO organizations."

The vast difference in performance between just the two OPOs (there are 58 total in the U.S.) -- 237.5% -- means that 206 additional potential donors could have been available if the first OPO had performed similarly to the second one, noted Robert M. Cannon, MD, MS, and Jayme E. Locke, MD, MPH, both of the University of Alabama at Birmingham Heersink School of Medicine, in an accompanying editorial.

"This gap between only 2 OPOs is of similar magnitude to the performance gap seen in all U.S. transplant centers," they wrote.

Karp and colleagues said that there is little understanding of the causes of variation among OPO procurement rates, "in part because relevant data are difficult to obtain. ... Some argue that blame lies with the failure of hospitals to refer ventilated patients to OPOs or with center acceptance practices."

According to Cannon and Locke, "the cold truth is that we have no good understanding of why some OPOs are better than others, or even what an acceptable level of OPO performance should be because the environment in which OPOs operate is so completely obscure."

For this study, Karp and team chose two donor service areas with two OPOs whose historic observed-to-expected donor metrics were the same, but who differed using a new metric, CMS CALC, which was implemented in 2022. The metrics historically used by OPOs, accessed through the Scientific Registry of Transplant Recipients, showed that the two OPOs had equivalent performances. This disparity in the performance-measuring metrics, the authors wrote, "suggests that historical performance metrics failed to find an actual difference in performance."

The newer metric considers death data from the National Center for Health Statistics, and "is an objective, independently reported measure" that captures the ratio of actual-to-potential donors more realistically, the authors added. The older metric was self-reported by OPOs and criticized for excluding certain potential donors and failing to capture actual OPO performance.

Although thousands of patients languish on donor lists each year, Karp said that it's a misconception that there aren't enough organs to go around. "It's not that people just don't want to donate. That's just simply not true," he noted. The problem, instead, is with the organ procurement system.

He suggested that OPOs that perform better build meaningful relationships with hospitals in order to coordinate a time-sensitive donation with a donor's family -- something that often involves in-person meetings and delicate conversations.

Co-author Malay B. Shah, MD, of the University of Kentucky in Lexington, noticed that organs he recovered for transplants were only coming from certain hospitals in his area. "People don't just die at the University of Kentucky, right? They die at other hospitals that have very robust services," he told MedPage Today. "Why do we not do donors [there]?"

Metrics that hold OPOs accountable for their ability to do this effectively make the disparities less obscure -- but they must be available publicly, Shah added. "We all need to be transparent about the work we're doing and and use it to improve."

In this study, Karp and colleagues reviewed 2,008 medical records for decedents from 2017-2018 as a sample of nearly 9,000 deaths.

Inpatient deaths were excluded as potential donors if they met certain medical criteria that would typically disqualify organ donation, such as multi-organ failure or cardiac arrest without return of spontaneous circulation.

The authors said it is possible that they over-counted the number of potential donors, but tried to control for this by using conservative criteria. In addition, bias could have been introduced by using only hospitals that could provide medical records. Furthermore, because their analysis included only two OPOs, their results may not be generalizable to others.

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