- Email: [email protected]
Organ donation during the financial crisis in Greece
Correspondence
*A Michael Lincoff, John H Alexander, Roxana Mehran [email protected] Cleveland Clinic Coordinating Center for Clinical Research (C5Research), Cleveland, OH, USA (AML); Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA (JHA); and Mount Sinai School of Medicine, New York, NY, USA (RM) 1
Lincoff AM, Mehran R, Povsic TJ, et al, on behalf of the REGULATE-PCI Investigators. Effect of the REG1 anticoagulation system versus bivalirudin on outcomes after percutaneous coronary intervention (REGULATE-PCI): a randomised clinical trial. Lancet 2016; 387: 349–56.
www.thelancet.com Vol 387 April 9, 2016
Greece is in the midst of a severe financial crisis that struck the country in 2008, which resulted in political instability, poor overall economic prospects, and reductions in public expenditure.1 Many problems that have long been identified by the Greek National Health System are now augmented because of the economic situation,2 and one such example is the rapid decrease in organ donation rates in the past two decades.3 Is this situation a direct result of the financial crisis, or did the financial crisis worsen an already problematic situation? We aim to answer this question by comparing the present status of organ
donation in Greece with data from other Mediterranean countries that were also affected by the financial crisis—namely, Portugal, Italy, and Spain. We analysed data in 2008 (before the crisis), 2011 (at the peak of the crisis), and 2014 (first report of return to financial growth) from the Hellenic Transplant Organization and International Registry In Organ Donation and Transplantation. Greece has the fewest organ donations among all European countries, and the number of solid organ transplantations from deceased donors declined from 255 (8·9 donors per million population) in 2008 to 185 (7·2 per million population) in 2011 and 147 (4·6 per million population) in 2014. Most organ donations in Greece were from deceased donors. The trend in
For the Hellenic Transplant Organization see http://www. eom.gr/ For the International Registry In Organ Donation and Transplantation see http:// www.irodat.org/?p=database
A 40 35 Donors per million population
AML reports institutional research support and travel reimbursement from Regado Biosciences, Roche, Genentech, Eli Lilly, Pfizer, and Takeda; institutional research support from AstraZeneca; institutional research support and consulting fees from CSL; consulting fees from Sermonix; and consulting fees and travel reimbursement from Amgen. RM reports consulting and/or advisory board fees from Regado Biosciences, Abbott Vascular, AstraZeneca, Boston Scientific, Covidien, CSL Behring, Janssen Pharmaceuticals, Maya Medical, Merck, and Sanofi-Aventis; and institutional research support from AstraZeneca, The Medicines Company, Bristol-Myers Squibb, Sanofi-Aventis, Lilly, and Daiichi Sankyo. JA reports grants and personal fees from Regado Biosciences, Bristol-Myers Squibb, Pfizer, and CSL Behring; grants from Boehringer Ingelheim, Sanofi, Tenax, Vivus; and personal fees from Janssen, Daiichi Sankyo, GlaxoSmithKline, Portola, Sohmalution, and Xoma, outside the submitted work. Duke University owned a small amount of equity in Regado Biosciences. The amount and terms of this equity are unknown to anyone involved in this project.
Organ donation during the financial crisis in Greece
30 25 20 15 10 5 0
B 4500
Living donor Deceased donor
4000 Number of solid organ transplantations
achieved; these endpoints are those included within the Article’s tables. In view of the unexpected early termination of the trial because of allergies, with only a quarter of the planned number of primary endpoint numbers accrued, we regarded all of the endpoints reported for this study as exploratory and made no definitive conclusions one way or the other regarding efficacy. We acknowledge that the trial entry on ClinicalTrials. gov did not include the prespecified secondary or tertiary endpoints. The trial was registered by the study sponsor, but we did not ensure that that registration was complete. We and our academic research groups recognise the importance of full public reporting of trial design and results, and we apologise for this oversight.
3873
3910
3639
3500 2945
3000
2994
2586
2500 2000 1500 1000
791
702
682
500 0
55
2008
47
57
2011
2014
Portugal
143
2008
226
2011 Italy
252 255 51
2014
2008
185
46
2011 Greece
147
39
2014
184
2008
444
340
2011
2014
Spain
Figure: (A) Donation rate from deceased donors and (B) number of solid organ transplantation in Portugal, Italy, Greece, and Spain
1511
Correspondence
transplantation from living donors was similar (figure), although only data from kidney transplantation were available. In 2008–14, Spain had a slight increase in donation rates and in the number of solid organ transplantations from both deceased and living donors (figure). Portugal has adopted the Spanish legal framework in 1993 and was consistently the second highest in organ donation ranking of 27 European countries in 2008–14, with 27·7 donors per million population and 682 solid organ transplantations from deceased donors in 2014. Italy also had satisfactory donation rates (23 donors per million population in 2014), which had increased from almost 0 living donor per million population in 1992 to almost 4·2 per million population in 2014.3 It is obvious that organ donation in these countries was relatively unaffected by the 2008 financial crisis, mainly because their relevant policies were able to maintain high donation rates and encourage contribution from living donors. The organ donation crisis in Greece does not exclusively represent direct negative effects of the financial crisis, but reflects the underlying inadequacy of the health system and people’s attitude towards organ donation. We declare no competing interests.
*Demetrios Moris, Georgios Zavos, Georgia Menoudakou, Antreas Karampinis, John Boletis [email protected] Transplantation Unit (DM, GZ, JB) and Department of Nephrology (JB), Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece; Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA (DM); and Hellenic Transplant Organization, Athens, Greece (GM, AK, JB) 1
2
3
1512
Kontos M, Moris D, Zografos N, Liakakos T. The Greek financial crisis: maintaining medical education against the odds. Postgrad Med J 2015; 91: 609–11. Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D. Health effects of financial crisis: omens of a Greek tragedy. Lancet 2011; 378: 1457–58. Midolo E, Minacori R, Panocchia N, et al. The legislation on living organ donation in western Europe: legal and ethical analysis and impact on clinical practice. Transplant Proc 2013; 45: 2576–79.
Are doctors in training being trained? In the Shape of Training report, 1 David Greenaway called for postgraduate medical education to become broader and shorter. In response, there have been numerous appeals to redesign health-care service delivery in the UK to reduce the reliance on doctors in training and to ensure that they spend more time developing their knowledge and skills. Just how much time do doctors in training actually spend in training? Results from a 2015 survey of foundation and early years surgical trainees done by the Royal College of Surgeons of England (990 responses) showed that in an average week, trainees perceive that 70% of their time is spent on service delivery, rather than training. Trainees consistently worked for longer hours than contracted, with many potentially compensating for the reduced training opportunities in their contracted working hours by working for longer. Trainees were asked to provide detailed information about the tasks they did during their last working shift. This cross-sectional survey revealed that, on average, doctors in training spend more than 3 h per day completing paperwork to discharge patients or administrative tasks and more than 1 h per day doing simple, practical procedures (eg, venepuncture). Administration was the single largest component of the average workload of a foundation trainee. In stark contrast with this, doctors in training receive, on average, just 13 min of bedside teaching, and 20 min of formal teaching or simulation training per day. Additionally, trainees were asked to rate the perceived educational value of various tasks. Perhaps unsurprisingly, the lowest educational value score was assigned to administrative tasks, whereas formal and bedside teaching activities were given the
highest educational value score. An unfortunate disconnect clearly exists between the educational value of a task and how much time is spent on it, because trainees are spending a substantial amount of time on activities that are perceived as having the lowest educational value. It was, however, noted that all tasks undertaken by junior doctors do have educational benefit and it is perhaps naive to suggest that any task can be solely classified as either service or training. More effort must be made to ensure that doctors in training spend a higher proportion of their time being educated and trained. Some clinicians have proposed better use of the wider health-care team to reduce the reliance on junior medical staff. In many countries, nurses and physician associates have an integral role in doing what were traditionally thought of as medical tasks. Clinicians in the UK should consider ways of making better use of complementary non-medical roles to ensure doctors in training are best equipped for the future. We declare no competing interests.
Matko Marlais, John Abraham Mathews, *Ian Eardley [email protected] The Royal College of Surgeons of England, 35–43 Lincoln’s Inn Fields, London WC2A 3PE, UK 1
Greenaway D. Shape of training: securing the future of excellent patient care. 2013. http://www.shapeoftraining.co.uk/static/ documents/content/Shape_of_training_ FINAL_Report.pdf_53977887.pdf (accessed Jan 14, 2016).
www.thelancet.com Vol 387 April 9, 2016
*A Michael Lincoff, John H Alexander, Roxana Mehran [email protected] Cleveland Clinic Coordinating Center for Clinical Research (C5Research), Cleveland, OH, USA (AML); Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA (JHA); and Mount Sinai School of Medicine, New York, NY, USA (RM) 1
Lincoff AM, Mehran R, Povsic TJ, et al, on behalf of the REGULATE-PCI Investigators. Effect of the REG1 anticoagulation system versus bivalirudin on outcomes after percutaneous coronary intervention (REGULATE-PCI): a randomised clinical trial. Lancet 2016; 387: 349–56.
www.thelancet.com Vol 387 April 9, 2016
Greece is in the midst of a severe financial crisis that struck the country in 2008, which resulted in political instability, poor overall economic prospects, and reductions in public expenditure.1 Many problems that have long been identified by the Greek National Health System are now augmented because of the economic situation,2 and one such example is the rapid decrease in organ donation rates in the past two decades.3 Is this situation a direct result of the financial crisis, or did the financial crisis worsen an already problematic situation? We aim to answer this question by comparing the present status of organ
donation in Greece with data from other Mediterranean countries that were also affected by the financial crisis—namely, Portugal, Italy, and Spain. We analysed data in 2008 (before the crisis), 2011 (at the peak of the crisis), and 2014 (first report of return to financial growth) from the Hellenic Transplant Organization and International Registry In Organ Donation and Transplantation. Greece has the fewest organ donations among all European countries, and the number of solid organ transplantations from deceased donors declined from 255 (8·9 donors per million population) in 2008 to 185 (7·2 per million population) in 2011 and 147 (4·6 per million population) in 2014. Most organ donations in Greece were from deceased donors. The trend in
For the Hellenic Transplant Organization see http://www. eom.gr/ For the International Registry In Organ Donation and Transplantation see http:// www.irodat.org/?p=database
A 40 35 Donors per million population
AML reports institutional research support and travel reimbursement from Regado Biosciences, Roche, Genentech, Eli Lilly, Pfizer, and Takeda; institutional research support from AstraZeneca; institutional research support and consulting fees from CSL; consulting fees from Sermonix; and consulting fees and travel reimbursement from Amgen. RM reports consulting and/or advisory board fees from Regado Biosciences, Abbott Vascular, AstraZeneca, Boston Scientific, Covidien, CSL Behring, Janssen Pharmaceuticals, Maya Medical, Merck, and Sanofi-Aventis; and institutional research support from AstraZeneca, The Medicines Company, Bristol-Myers Squibb, Sanofi-Aventis, Lilly, and Daiichi Sankyo. JA reports grants and personal fees from Regado Biosciences, Bristol-Myers Squibb, Pfizer, and CSL Behring; grants from Boehringer Ingelheim, Sanofi, Tenax, Vivus; and personal fees from Janssen, Daiichi Sankyo, GlaxoSmithKline, Portola, Sohmalution, and Xoma, outside the submitted work. Duke University owned a small amount of equity in Regado Biosciences. The amount and terms of this equity are unknown to anyone involved in this project.
Organ donation during the financial crisis in Greece
30 25 20 15 10 5 0
B 4500
Living donor Deceased donor
4000 Number of solid organ transplantations
achieved; these endpoints are those included within the Article’s tables. In view of the unexpected early termination of the trial because of allergies, with only a quarter of the planned number of primary endpoint numbers accrued, we regarded all of the endpoints reported for this study as exploratory and made no definitive conclusions one way or the other regarding efficacy. We acknowledge that the trial entry on ClinicalTrials. gov did not include the prespecified secondary or tertiary endpoints. The trial was registered by the study sponsor, but we did not ensure that that registration was complete. We and our academic research groups recognise the importance of full public reporting of trial design and results, and we apologise for this oversight.
3873
3910
3639
3500 2945
3000
2994
2586
2500 2000 1500 1000
791
702
682
500 0
55
2008
47
57
2011
2014
Portugal
143
2008
226
2011 Italy
252 255 51
2014
2008
185
46
2011 Greece
147
39
2014
184
2008
444
340
2011
2014
Spain
Figure: (A) Donation rate from deceased donors and (B) number of solid organ transplantation in Portugal, Italy, Greece, and Spain
1511
Correspondence
transplantation from living donors was similar (figure), although only data from kidney transplantation were available. In 2008–14, Spain had a slight increase in donation rates and in the number of solid organ transplantations from both deceased and living donors (figure). Portugal has adopted the Spanish legal framework in 1993 and was consistently the second highest in organ donation ranking of 27 European countries in 2008–14, with 27·7 donors per million population and 682 solid organ transplantations from deceased donors in 2014. Italy also had satisfactory donation rates (23 donors per million population in 2014), which had increased from almost 0 living donor per million population in 1992 to almost 4·2 per million population in 2014.3 It is obvious that organ donation in these countries was relatively unaffected by the 2008 financial crisis, mainly because their relevant policies were able to maintain high donation rates and encourage contribution from living donors. The organ donation crisis in Greece does not exclusively represent direct negative effects of the financial crisis, but reflects the underlying inadequacy of the health system and people’s attitude towards organ donation. We declare no competing interests.
*Demetrios Moris, Georgios Zavos, Georgia Menoudakou, Antreas Karampinis, John Boletis [email protected] Transplantation Unit (DM, GZ, JB) and Department of Nephrology (JB), Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece; Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA (DM); and Hellenic Transplant Organization, Athens, Greece (GM, AK, JB) 1
2
3
1512
Kontos M, Moris D, Zografos N, Liakakos T. The Greek financial crisis: maintaining medical education against the odds. Postgrad Med J 2015; 91: 609–11. Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D. Health effects of financial crisis: omens of a Greek tragedy. Lancet 2011; 378: 1457–58. Midolo E, Minacori R, Panocchia N, et al. The legislation on living organ donation in western Europe: legal and ethical analysis and impact on clinical practice. Transplant Proc 2013; 45: 2576–79.
Are doctors in training being trained? In the Shape of Training report, 1 David Greenaway called for postgraduate medical education to become broader and shorter. In response, there have been numerous appeals to redesign health-care service delivery in the UK to reduce the reliance on doctors in training and to ensure that they spend more time developing their knowledge and skills. Just how much time do doctors in training actually spend in training? Results from a 2015 survey of foundation and early years surgical trainees done by the Royal College of Surgeons of England (990 responses) showed that in an average week, trainees perceive that 70% of their time is spent on service delivery, rather than training. Trainees consistently worked for longer hours than contracted, with many potentially compensating for the reduced training opportunities in their contracted working hours by working for longer. Trainees were asked to provide detailed information about the tasks they did during their last working shift. This cross-sectional survey revealed that, on average, doctors in training spend more than 3 h per day completing paperwork to discharge patients or administrative tasks and more than 1 h per day doing simple, practical procedures (eg, venepuncture). Administration was the single largest component of the average workload of a foundation trainee. In stark contrast with this, doctors in training receive, on average, just 13 min of bedside teaching, and 20 min of formal teaching or simulation training per day. Additionally, trainees were asked to rate the perceived educational value of various tasks. Perhaps unsurprisingly, the lowest educational value score was assigned to administrative tasks, whereas formal and bedside teaching activities were given the
highest educational value score. An unfortunate disconnect clearly exists between the educational value of a task and how much time is spent on it, because trainees are spending a substantial amount of time on activities that are perceived as having the lowest educational value. It was, however, noted that all tasks undertaken by junior doctors do have educational benefit and it is perhaps naive to suggest that any task can be solely classified as either service or training. More effort must be made to ensure that doctors in training spend a higher proportion of their time being educated and trained. Some clinicians have proposed better use of the wider health-care team to reduce the reliance on junior medical staff. In many countries, nurses and physician associates have an integral role in doing what were traditionally thought of as medical tasks. Clinicians in the UK should consider ways of making better use of complementary non-medical roles to ensure doctors in training are best equipped for the future. We declare no competing interests.
Matko Marlais, John Abraham Mathews, *Ian Eardley [email protected] The Royal College of Surgeons of England, 35–43 Lincoln’s Inn Fields, London WC2A 3PE, UK 1
Greenaway D. Shape of training: securing the future of excellent patient care. 2013. http://www.shapeoftraining.co.uk/static/ documents/content/Shape_of_training_ FINAL_Report.pdf_53977887.pdf (accessed Jan 14, 2016).
www.thelancet.com Vol 387 April 9, 2016