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Training Hospital Transplantation Coordinators in Brazil
Training Hospital Transplantation Coordinators in Brazil V.D. Garcia, T. Miranda, L. Luca, R. Nothen, and J.B. Teixeira Pinto ABSTRACT In Brazil from 1993 to 1997, the rate of deceased organ donors did not increase, remaining fixed around 3 donors per million population (pmp/y). In 1997, seeking to improve this situation, we introduced a policy seeking to improve the transplantation rates. Among the organizational measures, we created hospital transplantation coordinators based on the Spanish model. Because there was not enough qualified personnel in this area, 18 basic courses (12 to 24 hours) were performed in 9 states, with the purpose to train 1020 coordinators. Furthermore 20 advanced courses (40 hours) were introduced to train these coordinators in 16 of the 21 Brazilian states that perform transplantations in addition to the Federal District, resulting in 920 new coordinators. As a consequence, there was a mean annual increase of 20% in donations, namely 600 deceased donors in 1999 (3.8 pmp), 840 in 2001 (5.2 pmp), and 1232 in 2004 (7.3 pmp). The potential rate of donors notification attained 4981 (29 pmp) in 2004, about 50% of the estimate figures. However, this rate is far lower than that necessary. It is important to continue coordination of new training (4 yearly) and retraining courses for qualified coordinators using 2-day intensive courses (16 hours).
T
HE BRAZILIAN population of 170 million inhabitants occupy an area of 8.5 million km2. Brazil is divided in 5 regions containing 27 states in addition to the Federal District (Fig 1). The yearly per capita income is about 3750 US $, and the yearly health expenditure per capita is 260 US $. Since 1988, there has been a public health system for the entire population. Most of the transplantation activities in Brazil began in the 1960’s: kidney transplantation in 1964, and liver, pancreas, heart, and small bowel transplantation in 1968. Simultaneous kidney-pancreas (1987) and lung transplantation (1989) were carried out in the 1980s. The first transplantation legislation was established in 1968; the Brazilian Transplant Association (ABTO) was created in 1986. Although some regional transplantation organizations have been functioning since 1987, the National Transplant Organization (SNT) was created only in 1998.1 PREVIOUS SITUATION
The number of deceased donors and organ transplantations increased until 1993 (Table 1). But from that year to 1998, the figure remained stabilized in Brazil; the only exception being liver transplantations, which increased. From 1993 to 1998, the deceased donor rates did not increase, remaining stabilized around 3 pmp/y from 400 to 480 deceased donors per year, and the rate of potential notified donors ranged from 12 to 16 pmp/y (Fig 2).1 0041-1345/07/$–see front matter doi:10.1016/j.transproceed.2007.01.018 336
Fig 1. Geographic division and population in 5 regions (million inhabitants) in Brazil.
Within that period, many problems occurred, such as lack of a national transplant organization, lack of transplantation coordinators, poor communication among regional From the Brazilian Association for Organ Transplantation, São Paulo, Brazil. Address reprint requests to Valter Duro Garcia, Rua Correa Lima 1493, Porto Alegre RS, Brazil CEP 90850-250. E-mail: [email protected] © 2007 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 39, 336 –338 (2007)
TRAINING IN BRAZIL
337
Table 1. Number and Rate of Organ Transplants Attained From Deceased Donors in Brazil From 1993 to 2004 Kidney
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Liver
Population (Million)
Per Capita GDP US $
Deceased Donor (pmp)
13 43 13 76 26 172
2010 1480 3230 4230 3680 3750
1.2 5.7 4.4 9.1 8.1 7.3
Kidney-Pancreas
N
pmp
N
pmp
N
pmp
734 860 932 862 790 860 1000 1219 1256 1185 1342 1728
4.5 5.2 5.7 5.2 4.7 5.1 6.0 7.2 7.4 7.0 7.9 10.2
70 73 131 196 215 259 334 437 474 516 615 757
0.4 0.4 0.8 1.2 1.3 1.6 2.0 2.6 2.8 3.0 3.6 4.5
1 0 0 5 7 1 8 37 87 143 163 160
0 0 0 ⬍0.1 ⬍0.1 ⬍0.1 ⬍0.1 0.2 0.5 0.8 1.0 0.9
transplant organizations, absence of retrieval teams on a 24-hour basis in some regions, waiting list controlled by each hospital and not by an independent organization, no reimbursement for organ procurement, and low payment for transplant recipient follow-up.2 TRAINING TRANSPLANTATION HOSPITAL COORDINATORS
In 1997, seeking to improve that situation, several measures introduced policies with financial, legal, organizational, and educational programs.2 Among the most important measures was the creation of a national transplantation organization and regional transplantation organizations in all states, including regional allocation and transparent waiting lists, and national funding for transplantation payment. Among the organizational measures was the creation of hospital transplantation coordinators based on the Spanish model.3,4 The functions of such professionals were organizing the donation, identifying potential donors, facilitating brain death diagnosis, and coordinating the family interview. Because there were not enough people qualified for this
Fig 2. Rate of potential and effective deceased organ donors obtained in Brazil from 1993 to 2004.
Table 2. Differences Observed as to the Per Capita GDP and Deceased Donor in the Brazilian Regions
North Northeast Midwest Southeast South Brazil
work, training courses were introduced for these coordinators. The aim of these courses was to grant a certificate to health workers to perform activities of hospital transplantation coordination, supplying knowledge and legal support. The courses were divided into 2 levels: basic (12–24 hours), which supported a temporary certificate to the hospital transplantation coordinator, and high (40 hours), which granted a definitive certificate to the hospital transplantation coordinator. Between 1997 and 2002, 1020 coordinators attended 18 basic level courses in 9 states, the majority organized by the ABTO, with course durations of 12–24 hours. Between 2000 and 2003, the Brazilian Health Department coordinated and sponsorsed the high level courses, which included 5 days of intensive study involving 40 class hours, training 40 to 60 professionals per course. The content of these courses included lectures, debates, case studies, simulated situations, and videos. With the purpose to decentralize the coordination courses and create a standard training program in the country, the courses were conducted in 16 of the 21 states in which transplantations were performed in addition to the Federal District, resulting in 920 new transplantation hospital coordinators. To lower costs, local professors and 4 professional experts organized the majority of the lectures. RESULTS
Since 1998, there was a mean annual increase of 16% in donations in Brazil using 600 deceased donors (3.8 pmp) in
338
1999, 840 (5.2 pmp) in 2001, and 1232 (7.3 pmp) in 2004 (Fig 2). The rate of potential notified donors reached 4981 (29 pmp) in 2004, about 50% of the estimated figure (60 pmp). As a consequence, the increase was greater than 100% in liver, kidney, and pancreas transplantations from 1998 to 2004 (Table 1). However, there were many differences in the donation rates between states, suggesting that despite all the measures, there is a need for more educational and organizational involvement in some states and regions, mainly the North region of the country (Table 2). In conclusion, although the rate is far less than that necessary, it is important to continue with the coordination, new training programs (4 per year), and retraining courses for qualified coordinators using 2-day intensive courses
GARCIA, MIRANDA, LUCA ET AL
(16 hours), besides other measures, to obtain yearly increases of 1 deceased donor per million population. REFERENCES 1. Garcia VD, Abbud Filho M, Keitel E, et al: Situação atual do processo doação – transplante. In Garcia VD (ed): Por uma Política de Transplantes no Brasil. São Paulo: Office Editora; 2000. p 15 2. Garcia VD, Campos H, Paula FJ, et al: Proposta de uma política de transplantes para o Brasil. In Garcia VD (ed): Por uma Política de Transplantes no Brasil. São Paulo: Office Editora; 2000, p 199 3. Matesanz R, Miranda B: The Spanish experience in organ donation. In Chapman JR, Deierhoi M, Wight C (eds): Organ and Tissue Donation for Transplantation. London: Arnold; 1997, p 361 4. Matesanz R, Miranda B, Felipe C: Nephrol Dial Transplant 9:475, 1994
T
HE BRAZILIAN population of 170 million inhabitants occupy an area of 8.5 million km2. Brazil is divided in 5 regions containing 27 states in addition to the Federal District (Fig 1). The yearly per capita income is about 3750 US $, and the yearly health expenditure per capita is 260 US $. Since 1988, there has been a public health system for the entire population. Most of the transplantation activities in Brazil began in the 1960’s: kidney transplantation in 1964, and liver, pancreas, heart, and small bowel transplantation in 1968. Simultaneous kidney-pancreas (1987) and lung transplantation (1989) were carried out in the 1980s. The first transplantation legislation was established in 1968; the Brazilian Transplant Association (ABTO) was created in 1986. Although some regional transplantation organizations have been functioning since 1987, the National Transplant Organization (SNT) was created only in 1998.1 PREVIOUS SITUATION
The number of deceased donors and organ transplantations increased until 1993 (Table 1). But from that year to 1998, the figure remained stabilized in Brazil; the only exception being liver transplantations, which increased. From 1993 to 1998, the deceased donor rates did not increase, remaining stabilized around 3 pmp/y from 400 to 480 deceased donors per year, and the rate of potential notified donors ranged from 12 to 16 pmp/y (Fig 2).1 0041-1345/07/$–see front matter doi:10.1016/j.transproceed.2007.01.018 336
Fig 1. Geographic division and population in 5 regions (million inhabitants) in Brazil.
Within that period, many problems occurred, such as lack of a national transplant organization, lack of transplantation coordinators, poor communication among regional From the Brazilian Association for Organ Transplantation, São Paulo, Brazil. Address reprint requests to Valter Duro Garcia, Rua Correa Lima 1493, Porto Alegre RS, Brazil CEP 90850-250. E-mail: [email protected] © 2007 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 39, 336 –338 (2007)
TRAINING IN BRAZIL
337
Table 1. Number and Rate of Organ Transplants Attained From Deceased Donors in Brazil From 1993 to 2004 Kidney
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Liver
Population (Million)
Per Capita GDP US $
Deceased Donor (pmp)
13 43 13 76 26 172
2010 1480 3230 4230 3680 3750
1.2 5.7 4.4 9.1 8.1 7.3
Kidney-Pancreas
N
pmp
N
pmp
N
pmp
734 860 932 862 790 860 1000 1219 1256 1185 1342 1728
4.5 5.2 5.7 5.2 4.7 5.1 6.0 7.2 7.4 7.0 7.9 10.2
70 73 131 196 215 259 334 437 474 516 615 757
0.4 0.4 0.8 1.2 1.3 1.6 2.0 2.6 2.8 3.0 3.6 4.5
1 0 0 5 7 1 8 37 87 143 163 160
0 0 0 ⬍0.1 ⬍0.1 ⬍0.1 ⬍0.1 0.2 0.5 0.8 1.0 0.9
transplant organizations, absence of retrieval teams on a 24-hour basis in some regions, waiting list controlled by each hospital and not by an independent organization, no reimbursement for organ procurement, and low payment for transplant recipient follow-up.2 TRAINING TRANSPLANTATION HOSPITAL COORDINATORS
In 1997, seeking to improve that situation, several measures introduced policies with financial, legal, organizational, and educational programs.2 Among the most important measures was the creation of a national transplantation organization and regional transplantation organizations in all states, including regional allocation and transparent waiting lists, and national funding for transplantation payment. Among the organizational measures was the creation of hospital transplantation coordinators based on the Spanish model.3,4 The functions of such professionals were organizing the donation, identifying potential donors, facilitating brain death diagnosis, and coordinating the family interview. Because there were not enough people qualified for this
Fig 2. Rate of potential and effective deceased organ donors obtained in Brazil from 1993 to 2004.
Table 2. Differences Observed as to the Per Capita GDP and Deceased Donor in the Brazilian Regions
North Northeast Midwest Southeast South Brazil
work, training courses were introduced for these coordinators. The aim of these courses was to grant a certificate to health workers to perform activities of hospital transplantation coordination, supplying knowledge and legal support. The courses were divided into 2 levels: basic (12–24 hours), which supported a temporary certificate to the hospital transplantation coordinator, and high (40 hours), which granted a definitive certificate to the hospital transplantation coordinator. Between 1997 and 2002, 1020 coordinators attended 18 basic level courses in 9 states, the majority organized by the ABTO, with course durations of 12–24 hours. Between 2000 and 2003, the Brazilian Health Department coordinated and sponsorsed the high level courses, which included 5 days of intensive study involving 40 class hours, training 40 to 60 professionals per course. The content of these courses included lectures, debates, case studies, simulated situations, and videos. With the purpose to decentralize the coordination courses and create a standard training program in the country, the courses were conducted in 16 of the 21 states in which transplantations were performed in addition to the Federal District, resulting in 920 new transplantation hospital coordinators. To lower costs, local professors and 4 professional experts organized the majority of the lectures. RESULTS
Since 1998, there was a mean annual increase of 16% in donations in Brazil using 600 deceased donors (3.8 pmp) in
338
1999, 840 (5.2 pmp) in 2001, and 1232 (7.3 pmp) in 2004 (Fig 2). The rate of potential notified donors reached 4981 (29 pmp) in 2004, about 50% of the estimated figure (60 pmp). As a consequence, the increase was greater than 100% in liver, kidney, and pancreas transplantations from 1998 to 2004 (Table 1). However, there were many differences in the donation rates between states, suggesting that despite all the measures, there is a need for more educational and organizational involvement in some states and regions, mainly the North region of the country (Table 2). In conclusion, although the rate is far less than that necessary, it is important to continue with the coordination, new training programs (4 per year), and retraining courses for qualified coordinators using 2-day intensive courses
GARCIA, MIRANDA, LUCA ET AL
(16 hours), besides other measures, to obtain yearly increases of 1 deceased donor per million population. REFERENCES 1. Garcia VD, Abbud Filho M, Keitel E, et al: Situação atual do processo doação – transplante. In Garcia VD (ed): Por uma Política de Transplantes no Brasil. São Paulo: Office Editora; 2000. p 15 2. Garcia VD, Campos H, Paula FJ, et al: Proposta de uma política de transplantes para o Brasil. In Garcia VD (ed): Por uma Política de Transplantes no Brasil. São Paulo: Office Editora; 2000, p 199 3. Matesanz R, Miranda B: The Spanish experience in organ donation. In Chapman JR, Deierhoi M, Wight C (eds): Organ and Tissue Donation for Transplantation. London: Arnold; 1997, p 361 4. Matesanz R, Miranda B, Felipe C: Nephrol Dial Transplant 9:475, 1994