Canadian Blood Services Submission to the Saskatchewan Standing Committee on Human Services
Kimberly Young Director, Donation and Transplantation
Dr. Peter Nickerson Medical Advisor, Donation and Transplantation
Sept. 12, 2016
• Biologics manufacturer and clinical services provider
• More than the national blood system:
− Since 2008, responsible for leadership and coordination for Canada’s organ and tissue donation and transplantation system
Canadian Blood Services Improving access to transplants for current and future patients
Canada’s organ donation and transplantation system Improving access to transplants for current and future patients
3
4
National donation and transplantation programs and services Areas of focus
Canadian Blood Services’ role
Strategic plan development and implementation
Clinical governance, and policy
Canadian Transplant Registry
Patient programs and services
System performance
improvement: data, analytics
Leading practices, professional and public education
Clinical governance Quality Management System to guide national programs and services Integrated planning
Kidney Paired Donation National high status sharing:
Highly sensitized liver, heart, lung
National Organ Waitlist Local listing and organ sharing
Develop leading practices and provide awareness and education services
Timely and accurate data for reporting and system improvement
• National web-based computer program that links organ donors with potential recipients
• Helps allocate living and deceased donor organs: nationally provincially
regionally
by organ by program
• Generates data needed to improve transplant system performance
What is the Canadian Transplant Registry?
National Organ Waitlist
National living donation : Kidney Paired Donation program
Programs and services Operational support
National allocation
Local allocation
better user experience
faster response integrated patient
enhanced listing and allocation improved
record
mobile and web Services friendly technology
security
What does a new integrated Canadian Transplant Registry have to offer?
6
Integrated network
Canadian Transplant Registry patient programs and services
Organ
Allocation,
Sensitized
Waitlist and allocation
Donation and transplantation CTR programs and services
8
National Organ Waitlist
All waitlist candidates listed by status, province and time on list
Allocation:
All deceased organ donors
Offers by level
1 to 4
Level 1
National allocation
High Status waitlist
candidates based on national rules
Level 2
Provincial allocation
Provincial allocation based
on provincial rules
Level 3
National allocation
Non-utilized
Allocation for organs not
matched against Level 1 or 2
Level 4
International allocation
Allocation for organs not
matched against Level 1, 2 or 3
• Creates transplant opportunities for recipients who have an incompatible living donor • These donors were previously lost • 452 transplants completed (as of Aug. 15, 2016) • Represents 13% / year of all donations from living donors in Canada
Kidney Paired Donation (KPD) - Launched 2008
• Real-time, online national listing of patients waiting for heart, lung, liver, pancreas, small bowel, stomach, and multi-organ transplants
• Replaced paper-based London Health Sciences Waitlist • 6,863 patients listed, 739 currently active (as of Aug. 15, 2016)
National Organ Waitlist (NOW) – Launched 2012
• Highly sensitized patients comprise ~ 20% of provincial waitlists, but historically receive <1% of available donor organs – these patients waited years (e.g., 16+) or died waiting
• There is a national agreement to share kidneys for highly sensitized kidney patients Equitable access • 247 transplants complete (Aug. 15, 2016)
Highly Sensitized Patient (HSP) program (national kidney allocation) – Launched 2013
9
Canadian Transplant Registry National Patient Programs
Improving access to transplants for current and future patients
10
• National leadership role in all provinces and territories
– Leading practices, professional and
public education
– Strategic plan development and implementation
– System performance improvement, data and analytics
– Canadian Transplant Registry, patient programs and services
OTDT program Improving access to transplants for current and future patients
Organ Donation and Transplantation in Canada: System Progress Report 2006–2015
11
System Progress Report
Key findings
System performance improvement
12
• Canada’s organ donation and transplantation rates are on the rise • Since 2006:
‒ National rate of deceased donation is up by 29 per cent; now among Top 20 in the world
‒ Number of transplants has increased by 23 per cent in Canada
‒ Three provinces in Canada (B.C., Ont. and Alta.) are close to reaching nationally set first-tier living donation targets for 2015 (20 dpmp)
Donation from deceased donors
39.7
28.5
20.2 18.3 18.2
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
Spa
inC
roa
tia
Bel
giu
mP
ort
ug
al
Ma
lta
*U
SA
Fra
nce
Slo
ven
iaC
zech
Rep
.*A
ust
ria
Fin
lan
dN
orw
ay
Ita
lyU
KB
ela
rus
La
tvia
Po
lan
dA
ust
rali
aC
an
ad
aH
un
ga
ryIr
ela
nd
Swit
zerl
an
dSl
ova
k R
ep.
Swed
enN
eth
erla
nd
sD
enm
ark
Bra
zil
Arg
enti
na
Uru
gu
ay
New
Zea
lan
dG
erm
an
yIr
an
Sou
th K
ore
aIs
rael
Ch
ile
Tu
rkey
Bu
lga
ria
Ho
ng
Ko
ng
Ro
ma
nia
Lu
xem
bu
rgo
Ru
ssia
Sau
di A
rab
iaT
rin
ida
d &
To
b.C
hin
aJa
pa
nG
eorg
ia
International deceased donation rates 2015 Donation from deceased donors
14 Source: International Data: http://www.irodat.org/img/database/pdf/NEWSLETTER2016_FirstEdition.pdf Canadian Data: 2016 Canadian Blood Services survey of Canadian transplant centres and organ donation organizations
* 2014 data
Deceased donors (dpmp) in Canada
Donation from deceased donors
15
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
20.0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Total NDD DCD
Deceased donation by province (pmp) Donation from deceased donors
16
22.0 target
23% 59% -19% -14% 23% 30% 13% -27% 4% -55%
-5.0
0.0
5.0
10.0
15.0
20.0
25.0
30.0
Cda. B.C.* Alta.** Sask. Man. Ont. Que. N.B. N.S.*** N.L.
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Notes *Rates for B.C. — population of Yukon is included **Rates for Alberta -–populations of NWT and Nunavut are included *** Rate for Nova Scotia – population of PEI is included
Deceased donation performance in Saskatchewan (pmp)
Deceased donation
17
0.0
5.0
10.0
15.0
20.0
25.0
30.0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Total PMP NDD PMP DCD PMP
Deceased donation information pyramid*
*adapted from the Australian Government, Australian Organ and Tissue Donation and Transplantation Authority, Annual Report 2013-2014, Figure 8: Australia's potential organ donor population.
Canadian deceased donation leading practice recommendations 2003–2015
Shemie et al, CMAJ 2006 Shemie et al, CMAJ 2006 Shemie et al, CMAJ 2006
Shemie et al, CMAJ 2013 Shemie et al, Can J Neurol Scie 2008
Shemie et al, CMAJ 2006 Shemie et al, CMAJ 2006
Shemie, MacDonald CMAJ 2013
Shemie et al, Int Care Med, 2014
Factors contributing to higher donation rates (2015) System improvement
20
B.C. ALTA. SASK. MAN. ONT. QUE. N.B. N.S. N.L.
Mandatory Referral *
Donation Physicians
NDD Leading Practices
DCD Programs
(% DCD donors)
(25%)
(13%)
(10%)
(0%)
(31%)
(11%)
(0%)
(15%)
(0%)
Donor Management LP
Deceased Donors (DPMP)
(Number of donors)
20.1**
(95)
12.2***
(52)
8.8
(10)
13.1
(17)
19.5
(269)
20.8
(172)
10.6
(8)
21.2****
(20)
15.2
(8)
2011-2015 % change DPMP 76 33 -17 89 22 26 14 -20 -20
Implementation complete or near completion Implementation in progress Implementation not started
* Mandatory consideration ** Population of Yukon included in calculation of this rate. *** Populations of Nunavut and the Northwest Territories included in calculation of this rate.
**** Donors from Prince Edward Island included in calculation of this rate.
Donation from living donors
Worldwide Actual Living Organ Donors 2015 (pmp) Donation from living donors
22
18.8 16.6 15.7
10.3
0
5
10
15
20
25
30
35
40
45
50
Tu
rkey
Co
sta
Ric
a*
Sou
th K
ore
a
Net
her
lan
ds
Cyp
rus*
Sau
di A
rab
ia
Isra
el
Icel
an
d
Den
ma
rk
Ku
wa
it*
US
A
Leb
an
on
*
New
Zea
lan
d
UK
Ca
na
da
Geo
rgia
Ira
n
Swed
en
No
rwa
y
Swit
zerl
an
d
Au
stra
lia
Arg
enti
na
Tri
nid
ad
&T
ob.
Ger
ma
ny
Bel
giu
m
Fra
nce
*
Au
stri
a
Irel
an
d
Bra
zil
Po
rtu
ga
l
Uru
gu
ay
Cro
ati
a
La
tvia
Ita
ly
Ho
ng
Ko
ng
Slo
vak
Rep
.
Hu
ng
ary
Ro
ma
nia
Fin
lan
d
Bel
aru
s
Ru
ssia
Po
lan
d
Bu
lga
ria
Source: International Data: http://www.irodat.org/img/database/pdf/NEWSLETTER2016_FirstEdition.pdf Canadian Data: 2016 Canadian Blood Services survey of Canadian transplant centres and organ donation organizations
* 2014 data
Worldwide Actual Living Organ Donors 2015 (pmp) Donation from living donors
23 Source: International Data: http://www.irodat.org/img/database/pdf/NEWSLETTER2016_FirstEdition.pdf Canadian Data: 2016 Canadian Blood Services survey of Canadian transplant centres and organ donation organizations
0
5
10
15
20
25
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Australia
Canada
Spain
United Kingdom
United States
Living donation by province (pmp) Donation from living donors
24
20.0 target
-9% 1% 8% -243% -89% -7% -2% -81%
-3000%
-2500%
-2000%
-1500%
-1000%
-500%
0%
500%
0
5
10
15
20
25
30
Can B.C.* Alta.** Sask. Man. Ont. Que. Atlantic
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Notes *Rates for B.C. — Population of Yukon is included **Rates for Alberta -– Populations of NWT & and Nunavut are included Atlantic includes New Brunswick, Nova Scotia, Prince Edward Island and Newfoundland and Labrador.
Living donation performance in Saskatchewan (pmp) Donation from living donors
25
0
5
10
15
20
25
30
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Living donors PMP KPD PMP
Best practices: Living donation
• Decrease lengthy work-up times for donors and recipients
• Strategic program reviews for organ donation organizations and transplant programs
• Support for patients pre- and post-transplant
• National programs that support living donors
• Testing and medical diagnostics
System performance improvement
26
Transplantation
28
2,074 2,142 2,076 2,093 2,116 2,131 2,235
2,363 2,356 2,559
1519 1588 1530 1577 1559 1698 1778 1803
1996
555 554 546 516 557 537 585 553 563
0
500
1,000
1,500
2,000
2,500
3,000
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
↑31% deceased donor
transplants
↑23% In all
transplants
↑1% living donor transplants
Transplants in Canada 2006–2015 Transplantation
Kidney transplants (pmp) From deceased and living donors
Transplantation
29
44.0 Target
12% 51% -8% -57% -35% 15% 27% -28%
-30000%
-25000%
-20000%
-15000%
-10000%
-5000%
0%
5000%
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
Can BC AB SK MB ON QC Atl
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 % Increase in 10 Years
30
29 30
35
15
2
21
27
15
27
14
21 23 22
14
0
17
7
17
11
8 7
13
1 2
10 8
10
3
0
5
10
15
20
25
30
35
40
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Transplantation
↓48% deceased donor
transplants
↓52% In all
transplants
↓63% living donor transplants
Transplants in Saskatchewan 2006–2015
CORR CIHI 2016 Report
31
2014 Prevalent End-Stage Kidney Disease Patients
B.C. Alta. Sask. Man. Ont. Pop (million)
2014 4.675405 4.200960 1.122283 1.280242 13.677687
Transplants pmp 560.1 506.3 421.5 520.2 528.8 Dialysis pmp 657.9 553.2 767.2 1107.6 815.7
Total ESRD pmp 1218.0 1059.5 1090.9 1627.8 1344.5
Burden of end-stage kidney disease equal in Alta. and Sask. • Sask. more reliant on dialysis rather than transplant • Therefore cost burden is greater in Sask. versus Alta.
Benefits of kidney transplant
Expected life years – Remaining on Dialysis versus receiving a transplant (Based on age of onset of end-stage kidney disease)
Benefits of kidney transplant
33
0 10 20 30 40 50 60
0-14
20-24
30-34
40-44
50-54
60-64
70-74
80-84
Additional Life Years
Age
Dialysis Transplant
Data for the figure supplied to the UNOS Kidney Transplant Committee by the United States Renal Data System (USRDS). Data available at www.usrds.org/2009/pdf/V2_06_09.pdf.
“Transplantation is the most cost-effective treatment for end-stage kidney disease.”
Benefits of kidney transplant
34
$40-$60K/year
Dialysis Cost
$40K Kidney Transplant
$10K Transplant Drug Therapy
Years
~$102M in cost savings for the health care system per year if all patients waiting at year end were transplant
Cost Avoidance
Opportunities for program improvement
Challenges and opportunities
Deceased donation
– Mandatory referral with death audit and accountability
– DCD and NDD optimization
– Donation specialist
Living donation
– Resourced to optimize capacity (provincial and national [kidney paired donation])
– Timely access to testing and donor evaluations
Opportunities for program improvement
36
Challenges and opportunities
Transplantation
– Lack of reliable data on transplantation and outcomes
– Varying criteria used to list patients, allocate and accept organs
System optimization
– Improvement strategy with clear targets and measures
– Rapid adoption of leading practices
Opportunities for program improvement
37
Challenges and opportunities
38
Elements of high-performing donation and transplant systems
• Customization— different challenges require unique strategies • National and international best practices — provinces that have applied
Canadian and international recommendations are seeing improvements • Sustained focus — improvement can be volatile as it evolves • Continued investment in the system— adequately resourced programs
and staffing models • Benchmarks — improvements must be tracked and adjusted
39
