Potential Disadvantages of Overcentralization of Organ Recovery Centers: Response to Marsolais et al
Bibliographic record
Abstract
To the Editor: As physicians involved in the Canadian organ donation system, we read with interest the report by Marsolais et al (1Marsolais P Durand P Charbonney E et al.The first 2 years of activity of a specialized organ procurement center: Report of an innovative approach to improve organ donation.Am J Transplant. 2017; 186: 95Google Scholar). While the team at Hôpital Sacre-Coeur de Montréal deserves to be congratulated for their excellence in the organ donation, the described model has potential disadvantages, and we believe its advantages have been overstated. Marsolais et al chose people transplanted per million (tpm) as their primary outcome, which is less frequently reported than donors per million. We disagree that tpm is the correct statistic, and we also disagree with how it was calculated. The authors carefully divide the donors referred to their hospital into those in and out of their service corridor, but they do not make a similar distinction for patients identified within their hospital (47% of their donors). The Hôpital Sacré-Coeur is part of a system serving the 3.8 million people of the metropolitan area (2Statistics Canada [Internet]. [cited 2013 Dec 2]. Available from: http://www.statcan.gc.ca/pub/84-215-x/2012001/table-tableau/tbl001-eng.htmGoogle Scholar). Patients are regularly diverted from one hospital to another, and people living in the corridor of one hospital might be injured in another. At a minimum, the authors could have presented sample donor rates based on differing assumptions of population. Finally, when comparing the rates of tmp with those of other jurisdictions, the authors misstate the actual rate in Spain to be 80.2 tmp instead of the 88.8 tmp reported in their cited reference (3Council of Europe and Organización Nacional de TrasplantesInternational figures on donation and transplantation-2013.Newsletter Transplant. 2014; 19: 96Google Scholar) and that of Canada to be 50.2 tmp instead of the 65–70 tpm reported in a recent national report (4Canadian Blood Services. Organ donation and transplantation in Canada - System Progress Report 2006–2015. 2016 Sep 8, 1–98.Google Scholar). While building a center of excellence likely improves conversion of potential to actual donors already at that site, the authors fail to mention consequences of transfer. They do not report potential harms that may occur during transport of severely neurologically injured patients. Also, were any potential donors lost to a lack of consent to transfer? In other jurisdictions, consent to transfer is a barrier to donation (personal communication, April 5, 2017, Andrew Healey, Chief Medical Officer, Trillium Gift of Life). It seems likely that some families refused, but this is unreported by the authors. The unacknowledged effects this model might have on enthusiasm for donation within the broader system are also important. Donation depends on prompt identification and initial management of potential donors wherever the patient presents. The experience of offering donation according to best practice and seeing a family complete the journey to donation reinforces the importance of this activity. The proposed model may threaten the system wide donation culture that is a key aspect of the Spanish model (5Matesanz R Dominguez-Gil B Coll E Mahíllo B Marazuela R How Spain reached 40 deceased organ donors per million population.Am J Transplant. 2017; 17: 1447-1454Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar). Increased expertise in the potential donor management and consent discussions is of critical import, but we are not convinced of the need for centralized recovery centers requiring distant transfers. Instead, we support a model that encourages all hospitals caring for the critically ill or injured to maintain excellence in potential donor identification, referral, consent, and management. With appropriate support from an organ donation organization, remote centers can maintain these patients in their hospitals, to the benefit of grieving families and the donation system as a whole. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.017 | 0.114 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.002 | 0.002 |
| Bibliometrics | 0.002 | 0.002 |
| Science and technology studies | 0.004 | 0.004 |
| Scholarly communication | 0.007 | 0.008 |
| Open science | 0.006 | 0.003 |
| Research integrity | 0.041 | 0.045 |
| Insufficient payload (model declined to judge) | 0.008 | 0.005 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".