Background: One U.S. organ procurement organization (OPO) has experienced rapid and sustained growth of both the organization and recovery rates since undertaking a complete organizational restructuring initiated in 2012.  Beginning with 2014 the OPO for six consecutive years set records for organ donors recovered, and for five consecutive years set records for the number of recovered organs transplanted.  The OPO sought to understand concurrent trends in non-productive and minimally productive donor cases both to improve management and to maximize opportunity for improvement.
Method: A retrospective review of all recovered donors and outcomes, as well as authorized-not recovered donors (ANR) was performed.  Data was analyzed for trends and classified to brain dead donors (DBD), donation after circulatory death donors (DCD), and ANRs; it was further sub-categorized to donors with zero organs transplanted (0-TX), one organ transplanted (1-TX), and multiple organs transplanted (M-TX). Organs recovered for transplant and either discarded or sent for research were also tracked.
Results: Organ donors recovered increased from 89 in 2013 to 197 in 2019 (+121%); DBD increased from 71 to 117 (+66%) and DCD increased from 18 to 80 (+344%). Of these, 0-TX donors increased from 5 to 28 (+460%), 1-TX donors increased from 9 to 23 (+156%), and M-TX increased from 75 to 146 (+95%).  Concurrently, ANR increased from 18 to 87 (+383%). Total donor cases worked (recovered plus ANR) increased from 107 to 284 (+165%). The number of organs transplanted increased from 289 to 516 (+79%). Organs recovered for transplant but not transplanted increased from 39 to 121 (+210%).
Discussion: Achieving significant growth in donors and organs transplanted was achieved by increases in both DBD and DCD. To achieve this growth, we found increasing the number of low-and-no-yield activity was necessary. In our experience, recovering 121% more donors and providing 79% more organs for transplant required 165% more cases to be worked by the OPO and 210% more organs recovered for transplant not being utilized. The implications are that OPOs should expect (1) that the rate of increase in donors will be outpaced by case volume and by low or no yield activity; (2) the rate of increase in organs transplanted will be less than either the cases worked or donors recovered; (3) additional investment in human and material resources will be required to successfully maximize donation and transplant, and the rate of return on these investments will be lower as the OPO recovers more DCD and complex DBD donors; (4) the number of organs recovered but not transplanted represents an opportunity for further improvement in performance for OPOs and transplant centers alike.