Our analysis shows that both the deceased donation activity and efficiency of the Swiss deceased organ donation program increased substantially during the last decade. Despite the measures implemented so far, the efficiency of the Swiss donation program stays below the French and Austrian programs. As a result of the improved efficiency in the conversion of the potential into donors, the Swiss program showed a moderately higher performance than the Italian program at the end of the study period.
Donation and transplant activity
The Swiss deceased donation activity (annual donation rate; range 12.0–17.4 pmp, mean 14.0 pmp) during the study period was lower than in Italy, France and Austria which had annual donation rates > 20 pmp (Italy, Austria), and > 23 pmp (France) in each year between 2008 and 2015 [
14].
Patient characteristics of Swiss donors during the decade preceding our study period showed a marked increase in the mean age of donors [
27]. In our study period, the mean donor age remained roughly stable (similar to the most recent historic data). Also, the mean donor age of Swiss donors between 2008 and 2017 is comparable to the mean age of French donors in recent years [
28]. In 2016 (latest ADD data published for the neighboring countries), the average number of transplants enabled per donor in Switzerland (3.3) was similar to Germany (3.4) and Austria (3.1), and higher than in France (2.7) and Italy (2.3) [
15]. This means that in countries with relatively low donation rates, a higher transplant rate per donor may compensate, at least partially, for the low donation activity. One should keep in mind, however, that a more liberal use of extended criteria donors (i.e., older donors and/or donors whose medical conditions are considered suboptimal) may be only suitable for selected subgroups of recipients, and may impact the transplant outcome [
29‐
32]. When comparing average numbers of transplants enabled per donor, it is also important to consider the fact that the percentage of DCD donors in Switzerland (14% in 2016) was markedly higher than in the other countries with a DCD program (Italy, 1.4%; Austria, 2.8%; France, 4.8%) [
15]. Because in the countries included in the study, the heart may be transplanted only from DBD donors, a larger proportion of DCD donors leads per se to a reduced average number of transplants enabled in the totality of DBD and DCD donors.
As DCD may be considered as supplementary to DBD, the reintroduction of the Swiss DCD program has successfully contributed to the increase of the number of organs available for transplantation [
3,
33]. As a matter of fact, 222 grafts from DCD donors have been transplanted to patients on the Swiss waiting list since September 2011. This represents additional life-years and quality of life gained by a considerable number of recipients. Because kidney transplants are cost-saving compared with dialysis for patients with end-stage renal failure, additional kidneys from DCD donors have also a beneficial effect on health care expenditure [
34]. Long-term outcomes of transplants with kidneys and lungs from DCD donors seem to be similar compared with grafts from DBD donors [
35‐
42]. Liver transplant outcomes from DCD donors have been reported as sometimes inferior compared to DBD, especially after prolonged warm ischemia time [
35,
43‐
45].
Donation efficiency in comparison with neighboring countries
The improved efficiency of the Swiss donation program suggests that the measures implemented were effective. A considerable proportion of the DCI increase, however, was due to the reintroduction of DCD. The DBD efficiency also increased over time, but less pronouncedly. Due to the relatively small absolute number of donors per year in small countries, annual DCI variations may occur (such as in 2016 in Switzerland or the see-sawing of the Austrian DCI). Yet, the evolution of the Swiss DCI shows a clear trend of increasing donation efficiency since 2012.
When considering possible reasons for differences in DCI between the countries, the consent rate (proportion of patients and/or families consenting to organ donation) is one factor that has a major impact on the DCI. Even though there is no internationally standardized way to report consent rates, published data show important differences between countries [
5‐
8,
46,
47]. According to 2012–2016 SwissPOD data, the overall consent rate of patients who deceased in the participating Swiss intensive care units was 43.5% [
7]. This suggests that roughly half of the donor potential was lost due to either patients or their next of kin not consenting to organ donation. In contrast, recent data from France, Austria and Italy (no data available for Germany) indicate that in these countries, only approximately one third of the potential was not converted because of patients or next of kin not consenting to organ donation [
15,
28]. If the consent rate in Switzerland was similar to the approximately 70% consent rate in France, Austria and Italy, the 2017 Swiss DCI would be estimated at about 3.8% (2.7% divided by 0.5 and multiplied by 0.7). Therefore, improving the consent rate in Switzerland should result in a significant additional efficiency increase of the Swiss donation program.
Evaluation of the current situation and outlook
In comparison with the neighboring countries and as discussed above, the performance of the Swiss organ donation and transplant program can be considered equal or slightly better, as the average number of transplants enabled per donor is similar to figures in Germany and Austria, and higher than in France and Italy. The relatively high number of transplants per donor contributes substantially to the overall performance of the Swiss donation program as it ensures an optimized use of the limited donor pool.
One factor that clearly has a negative impact on the donation activity and efficiency in Switzerland is the low consent rate which is in contrast to the largely positive attitude towards organ donation and transplantation among the Swiss population [
48‐
51]. Under the assumption that the consent policy (explicit consent in Switzerland and Germany, presumed consent in France, Austria, and Italy) may have an impact on the consent rate, it seems appropriate to consider changing the Swiss policy in order to achieve the Federal action plan’s goal of a refusal rate below 40% [
10,
52]. The fact that the consent rate in Switzerland has been roughly stable during the study period indicates, however, that the growth in efficiency may have resulted, at least to some degree, from the measures implemented. Naturally, there is no guarantee that a change in the system to presumed consent in Switzerland would per se lead to an increased rate of donors. Previous studies have pointed out that awareness of the consent policy may play an important role, and that changing the policy to presumed consent requires adequate and continuous information of the population [
53‐
57]. Efforts in Switzerland during the last decade have led to an efficient organ donation process, and the consent rate remains the action area with the most potential for a growth in the numbers of donors.
Action areas of the action plan included the training of healthcare professionals, the implementation of standardized processes and quality management, as well as optimizing structures and allocating resources in the hospitals [
12,
58]. Swisstransplant and the CNDO were commissioned by the FOPH and the cantons to accomplish these tasks.
The training of health care professionals has been standardized and integrated in a newly created blended learning program, established in 2015. The blended learning program consists of ten e-learning modules, and two face-to-face courses (“communication with next of kin” and “medicine and quality in the donation process”). Since its introduction, roughly one thousand health care professionals have been enrolled in the program. Hospital staff in charge with tasks related to organ donation (the 150 local organ and tissue donation coordinators) are required to complete the program and pass the final exam within two years.
As an additional measure and since mid-2016, earmarked funds are being allocated to the local organ and tissue donation coordinators. The allocation of earmarked funds has been a crucial step in the optimization of the donation process. First, because these funds recompense defined percentages of coordinators’ working time. Second and related, it is bound to enhanced accountability concerning the specific tasks of the coordinators. All hospitals with an accredited intensive care unit are contractually obliged to designate a local organ and tissue donation coordinator. To ensure a 24/7 donation coordination, the hospitals are clustered into donation networks, with each network having an on-call service for donation coordination.
The optimization of structures and processes included, among others, the involvement of accident and emergency departments as well as paramedics, and the ongoing training of staff. While the action plan mainly focused on optimizing the prerequisites for donation, one should bear in mind that there are other areas where there may be additional potential for improvement. For example, in donor management, procurement and ex-vivo conditioning [
59‐
62], or in the prevention and treatment of diseases leading to terminal organ failure which could result in less patients who need to be waitlisted for an organ transplantation [
63‐
65].
Finally, an evaluation of the performance of the Swiss organ donation and transplant program should take into account that its ultimate goal is to enable a maximum of transplants with a successful outcome. Outcome data for transplant recipients in Switzerland are generally similar or slightly better than the results reported in large international registries [
66‐
69]. In view of the high average number of organs transplanted per donor, and the relatively high mean donor age (e.g., compared with US data [
70]), this is an excellent result in terms of quality of care provided by the Swiss transplant centers.
Study strengths and limitations
Our study has several strengths and limitations. We consider it the main strength that it provides key figures on the evolution of the Swiss organ donation and transplant program during the last decade. These data, in combination with the assessment of the donation efficiency, should allow the reader to gain a general overview on the performance of the Swiss organ donation program. It also provides the context for a comparison with the performance of the donation programs in the neighboring countries.
Limitations of the DCI include that the mortality from the selected causes allows only for an approximation of the potential, and that international mortality data was only available until 2015 (for a detailed discussion of the DCI’s limitations see [
14]). The 2016 and 2017 DCI values of all countries included in our study are based on the latest mortality data available (2015). The 2017 DCI values of Austria, Italy, and Germany were calculated based on utilized donors instead of ADD, as at the time of the writing of this paper and to the best of our knowledge, ADD data had not yet been published. This may lead to a slightly underestimated DCI for these donation programs in 2017. A final word of caution should be given regarding the international comparability of consent rates. Due to non-standardized modalities of consent rate reporting, the data may not be completely comparable.