It appears that a national agency or mechanism for allocating donated organs for transplantation isn’t in the cards. But after four years of wrangling with provincial governments and transplant programs, Canadian Blood Services (CBS) has proposed a strategic plan for an “integrated interprovincial organ donation and transplantation system” that, if created by 2017, would at least help to reduce current inequities in access to organs and vastly improve Canada’s current “mediocre” performance with respect to organ transplantation rates.
Although the proposal does not feature any manner of mandatory organ sharing between jurisdictions or pan-Canadian organ allocation, CBS Chief Executive Officer Dr. Graham Sher told a press conference there’s enough “good will” within the transplant community to implement at least a measure of agreed-upon reforms to improve the system’s overall performance.
And if governments cough up $800 million over 10 years, it would result in about 7000 additional organ transplants in Canada, Sher said.
The proposal, Call to Action: A strategic plan to improve organ and tissue donation and transplantation performance for Canadians, also proposes to essentially create a separate system for dealing with tissue transplantations (www.organsandtissues.ca/s/wp-content/uploads/2012/06/OTDT-INDX-final-C2A.pdf).
CBS would be mandated to operate “a single interprovincial inventory and distribution system that provides equitable and timely access to tissues for hospitals and clinicians across the country” and assume responsibility for importing the estimated $40-million to $47-million worth of tissue (primarily skin, heart valves, bones and tendons) now obtained from foreign sources, which fulfill 80% of Canada’s needs.
Structural and governance reforms surrounding tissue transplantation have been tentatively priced at $37 million per year and could be expected to result in a doubling in the number of tissue allografts (currently 40 000 per year) and an increase of about 1100 corneal transplants each year, Sher said.
There were 2153 organ transplants in Canada in 2010, including 1234 kidneys, 443 livers, 167 hearts and 178 lungs, according to the Canadian Organ Replacement Register. There were 4529 Canadians on the waiting lists, 511 people who withdrew their names from waiting lists and 247 people who died while on the list.
Meanwhile, Canadian organ and tissue donation rates pale in comparison to other nations. At 13.9 deceased organ donations per million population in 2010 (a decrease from 14.4 in 2008), the Canadian rate lagged substantially behind the rates of nations such as the United Kingdom (15.5), the United States (26.1) and Spain (32.1). At 16 tissue donors per million population, Canada again lagged behind the US (99 per million).
CBS Chair Leah Hollins called the proposed regime a “game changer” and a “different kind of plan,” while Sher said its implementation would mitigate the “unacceptable” detrimental effects of maintaining the status quo. “In Canada, we have seen stagnant performance for over a decade in organ and tissue donation and transplantation. Today, we do not meet the needs of Canadian patients. … And the lack of an integrated system means that there is inequitable access across the country.”
“The system in Canada today lacks clear accountability between programs, between regions and between provinces,” he added. “Coordination amongst and between programs is ad hoc at best.”
While the London Transplant Program in Ontario maintains a list of “status 4” urgent need cases for hearts and there is forum for sharing livers on a similar basis, there is little kidney sharing between jurisdictions. The system is a quintessential reflection of fractured Canadian jurisdiction over health care and the upshot is that there is widespread variation by province in the wait times for available organs (www.cmaj.ca/lookup/doi/10.1503/cmaj.061256).
The proposed new system would essentially allow provinces to continue to retain total authority over organs within their boundaries but would create a complex governance structure, which would include an organ donation and transplant committee that would oversee development of overarching policies, performance indicators and accountability mechanisms. The new system would also collect and manage national data, develop strategies to improve organ donation rates and maintain specialized patient organ registries.
What CBS is recommending “is that there be a table created that has all provincial jurisdictions represented,” Dr. Peter Nickerson, associate dean of research at the University of Manitoba in Winnipeg and CBS medical director of transplantation told an earlier technical briefing on the plan. “That table would develop policy recommendations and that they would develop an accountability framework for organ donation and transplantation.”
The proposed system respects provincial jurisdiction, added Dr. Sam Shemie, a physician in the Division of Pediatric Critical Care at Montreal Children’s Hospital in Quebec and CBS medical director for organs and tissues donation. “We are not a national authority that is going to tell the provinces how to use their organs. That’s not what we are. What we are is a coordinating system that will, with provinces, set the rules for sharing of organs between provinces. But within the provinces, the way a province uses their organ internally is their decision and to use and allocate the way they decide for their population.”
Asked why the plan’s framers rejected the option of a national agency or mechanism for allocating organs, Sher said: “We were asked by the provincial and territorial governments to make sure that any plan and set of recommendations that were brought forward built on the existing infrastructure and programs that exist as opposed to essentially throwing the baby out with the bathwater and start again.”
As for whether the proposed system would reduce inequities in wait times, Sher said that if the recommendations are implemented, “we will see a significant balancing of that inequity. That will happen by essentially causing all boats to rise with the tide here. By increasing the performance in all regions in the country, we will see a narrowing of the differential that exists today.”