Disparities Affecting Organ Donation Rates in Chile

Organ transplantation represents a life-saving procedure for patients with end-stage organ failure.1 The demand for organ and tissue donation has increased substantially, and waiting times have increased considerably.2 Clearly, low numbers of organ donors represent a critical public health concern. At the same time, expanding organ donation is challenged by the limited number of suitable donors amid the ever-growing demand from potential recipients. Global efforts have been made to address this challenge through the implementation of diverse strategies, including the implementation of opt-out organ donation systems,3 donation after circulatory death,4 and an increased acceptance of marginal donors. However, those strategies have thus far not been able to meet the ever-increasing demand.5 The success of organ donation is usually measured by the annual deceased donation rate per million population (dpm).6 Chile exhibits one of the lowest organ donation rates compared with other Latin American countries. According to the latest reports, the dpm rate for 2021 stood at a meager 7.4 dpm7 when compared with global leaders in organ donation, including Spain (49.61 dpm) and the United States (36.8 dpm).8 Chile has a one-of-a-kind geography with the world's largest north–south extension9 (Figure 1). The country's capital Santiago is located in the center, whereas regions far to the north or south are challenged by geographical disparities when compared with more central regions10—a widely discussed centralism issue. These regional discrepancies may also decidedly impact the rates of organ donation throughout the nation.FIGURE 1.: Map of Chile indicating approximate distances to the northern and southern regions using Santiago as a reference point.For patients requiring kidney transplants, Santiago offers many options with 6 public and 8 private transplant centers located in the city. Patients can access an additional 7 transplant centers throughout the country. However, there are significant geographic disparities with no transplant center in northern regions. For those living in the southern regions, 4 transplant hubs can be found at varying distances of 122, 256, 499, and 680 km from Santiago. One of the most controversial topics in Chile regarding organ donation are the low organ donation rates in peripheral regions in addition to low organ donation rates in private sector hospitals. GEOGRAPHIC DISPARITIES Based on the 2017 Chilean National Census11 and data listed on the "Yo dono vida" website with transplants performed between 2010 and 2021,7 we calculated organ donor rates (per million habitants) by geographical region using the number of donors as the numerator,12 and the region's population in the 2017 census as the denominator13 based on data from public and private healthcare institutions. The percentage of people that have private insurance has declined and shifted toward the public insurance, partly due to discussions focusing on implementing a universal healthcare system14 (700 000 people switched just in 202315). We estimate that approximately 20% of the population is currently privately insured and used the estimate of donors from private institutions as the numerator.16 The "Red Nacional de Procuramiento de Organos y Tejidos" document (2019) assessed the number of hired nursing staff and physician hours. GEOGRAPHICE DISPARITES IN ORGAN DONATION Relevant differences between Chile's capital and the regions appear obvious (Table 1). The overall 10-y average national organ donation rate was 5 dpm. In a more detailed analysis, donation rates of peripheral regions were 4.77 dpm compared with 8.67 dpm in Santiago. Of relevance, the annual organ donation rate was 82% higher in Santiago than in other areas of the country (P < 0.001). TABLE 1. - Organ donation rates expressed as donors per million habitants in Chile 2010–2022, by geographic region Region Population No. of donors Organ donors per million habitantsa Northern Arica y Parinacota 257 722 4 1.29 Tarapacá 396 697 16 3.36 Antofagasta 709 637 37 4.34 Atacama 318 004 24 6.28 Central Coquimbo 858 769 50 4.85 Valparaíso y San Antonio 1 995 538 169 7.05 Region Metropolitana 8 310 984 865 8.67 O'Higgins 1 009 552 76 6.27 Maule 1 153 043 51 3.68 Ñuble 517 060 49 7.89 Southern Bío-Bío 1 676 269 106 5.26 Araucanía 1 024 029 46 3.74 Los Rios 409 559 28 5.69 Los Lagos 902 510 68 6.27 Aysén 108 047 0 0 Magallanes y la Antártica 181 143 12 5.52 Overall 19 828 563 1601 5.0 (average) aThis rate represents a 10-y average between 2010 and 2021. In addition to geographic disparities, Chile is challenged by vast differences in organ donation rates between public and private institutions (6 dpm in public versus 0.91 dpm in private institutions, P < 0.01; Table 2). TABLE 2. - Organ donation rate (donors per million habitants) in Chile 2010–2022, stratified by type of healthcare institution and geographic region Region Estimated public institutions population Estimated private institutions population Public institution donors Private institution donors Public institutions organ donation ratea Private institutions organ donation ratea Northern Arica y Parinacota 206 177.6 51 544.4 4 0 1.61 0 Tarapacá 317 357.6 79 339.4 16 0 4.20 0 Antofagasta 567 709.6 141 927.4 37 0 5.43 0 Atacama 254 403.2 63 600.8 24 0 7.86 0 Central Coquimbo 687 015.2 171 753.8 50 0 6.06 0 Valparaíso y San Antonio 1 596 430.4 399 107.6 167 2 8.71 0.41 Region Metropolitana 6 648 787.2 1 662 196.8 658 207 8.24 10.37 O'Higgins 807 641.6 201 910.4 76 0 7.84 0 Maule 922 434.4 230 608.6 51 0 4.60 0 Ñuble 413 648 103 412 48 1 9.67 0.80 Southern Bío-Bío 1 341 015.2 335 253.8 101 5 6.27 1.24 Araucanía 819 223.2 204 805.8 44 2 4.47 0.81 Los Rios 327 647.2 81 911.8 28 0 7.12 0 Los Lagos 722 008 180 502 66 2 7.61 0.92 Aysén 86 437.6 21 609.4 0 0 0 0 Magallanes y la Antártica 144 914.4 36 228.6 12 0 6.90 0 Overall 15 862 850.4 3 965 712.6 1382 219 6.0 (average) 0.91 (average) Estimation of public and private institution population was made based on the percentage of the population with public and private insurance in every region, not on publicly available registries with the bulk data.aThis rate represents a 10-y average between 2010 and 2021. The estimated 10-y average for organ donation was 6.5 times higher in public compared with private institutions. Nevertheless, when assessing these differences in the capital Santiago, differences between private and public institutions were less pronounced (10.37 versus 8.24 dpm, respectively). There were also significant differences in terms of staffing. Calculating the number of full-time organ procurement nurses and physicians (44 h/wk) by region and million habitants based on publicly available data (Table 3). We observed a national average of 4.2 full-time procurement nurses and 0.22 full-time procurement physicians per million inhabitants with significantly higher numbers of full-time procurement nurses in regions compared with Santiago (4.08 versus 2.17, respectively). TABLE 3. - Number of full-time (44 h) organ procurement physicians and nurses per administrative region of Chile (per million habitants) between 2010 and 2021 Region Organ procurement nurse/million inhabitants Organ procurement physicians/million inhabitants Northern Arica y Parinacota 3.88 1.94 Tarapacá 2.52 0.34 Antofagasta 2.81 0 Atacama 9.43 0 Central Coquimbo 3.4 0.18 Valparaíso y San Antonio 3.5 0.12 Region Metropolitana 2.16 0.12 O'Higgins 3.96 0 Maule 3.46 0.31 Ñuble 5.8 0.48 Southern Bío-Bío 4.77 0 Araucanía 1.95 0 Los Rios 2.44 0 Los Lagos 7.75 0.05 Aysén 0 0 Magallanes y la Antártica 5.52 0 Overall 4.2 (average) 0.22 (average) SUMMARY AND CONCLUSIONS Geographic disparities in organ donation rates represent a pressing issue in Chile, with potential explanations including variations in healthcare infrastructure, funding, and challenges in transportation logistics. Regions have the broadest difference in organ donation rates between public and private institutions, with private institutions providing only a fraction of the donors. Because most private institutions in peripheral regions are small-volume hospitals, one possible explanation is that institution size and complexity may play a pivotal role in the efficacy of organ procurement efforts. Further examination of the data supports the vital role played by organ procurement nursing professionals in positively influencing organ donation rates; this may be due to a more personalized approach and an overall higher availability at times when consent for organ donation is required. A lack of efficient communication with donor families, delays, and issues with the neurological determination of death, requiring a neurologist or neurosurgeon to confirm the diagnosis, or logistic problems in mobilizing organ procurement teams may be some of the explanations for not capturing suitable organs. Overall, geographic differences in organ donation in Chile emphasize on the need for comprehensive public policy changes to address these disparities, mainly focusing on geographic-specific educational campaigns in regions, facilitating access to diagnose neurological determination of death in a timely manner, addition to providing support for organ procurement teams while strengthening local procurement teams.