SOLID ORGAN TRANSPLANTATION (SOT) DURING COVID-19 PANDEMIC:
Lessons from an International Web-based Survey on Equity in Resource Allocation
Supplemental Digital Content
Table S1. Stratification according to Region.
Table S2. Subanalysis of geographic areas for the 2 nations with the largest number of answers
Table S3. Stratification according to Specialty.
Table S4. Stratification according to Organ of Interest.
Table S5. Thematic analysis of reasons for responses
2
Table S1.
Stratification according to Region
Italy Europe Americas Asia Australia
Africa Total
No. (%) No. (%) No. (%) No. (%) No. (%)
Position
Transplant Area 302 50.4 379 76.1 196 56.8 115 57.8 996 54.9
COVID-19 Area 221 36.9 69 13.9 101 29.3 51 25.6 446 24.6
Ethicists 33 5.5 19 3.8 16 4.6 6 3.0 75 4.1
Other 43 7.2 31 6.2 32 9.3 27 13.6 296 16.3
* *
Total 599 100.0 498 100.0 345 100.0 199 100.0 1813 100.0 Experience level
Trainee 69 12.2 59 12.3 13 4.0 26 13.9 171 10.9
Appointed 263 46.4 182 38.1 147 45.4 56 29.9 650 41.6
Head of Team 235 41.4 237 49,5 164 50,6 105 56.1 743 47.5
Total 567 100.0 478 100.0 324 100.0 187 100.0 1564 100.0 Organ of Interesta
Liver 87 35.3 106 32,5 68 43.3 49 53.8 311 37.8
Liver or Kidney 55 22.2 56 17,1 40 25.5 16 17,5 167 20.3
Kidney or kidney-pancreas 68 27.4 117 35.9 31 19.7 14 15.4 230 27.9 Heart or Lung or Heart-Lung 30 12.1 42 12.9 17 10.8 4 4.4 93 11.3
General Surgeons 8 3.2 5 1.5 1 0.6 8 8.8 22 2.7
Total 248 100.0 326 100.0 157 100.0 91 100.0 823 100.0 Stop Transplants
Not at all 200 37.6 51 11.1 34 10.9 17 9.7 314 19.8
Selectively 308 57.9 349 76,2 254 81,4 127 72.6 1119 70.7
Completely 24 4.5 58 12.7 24 7.7 31 17.7 149 9.4
* *
Total 532 100.0 458 100.0 312 100.0 175 100.0 1582 100.0 Equity resources distribution
Strongly agree 111 25.9 141 35.1 95 35.7 68 46.3 419 33.5
Partially agree 222 51.7 189 47.0 142 53,4 56 38.1 611 48.8
Partially disagree 73 17.0 53 13.2 19 7.1 18 12.2 165 13.2
Strongly disagree 23 5.4 19 4.7 10 3.8 5 3.4 57 4.6
Total 429 100.0 402 100.0 266 100.0 147 100.0 1252 100.0 Living Related Transplants
In urgent cases 269 61.7 224 55.9 158 58.3 121 76.1 793 60.7
In al scheduled cases 55 12.6 23 5.7 11 4.1 16 10.1 111 8.5
Never 112 25.7 154 38.4 102 37.6 22 13.8 402 30.8
* *
Total 436 100.0 401 100.0 271 100.0 159 100.0 1306 100.0 Health System
Public, Universal Coverage 565 94.7 439 89,0 69 20.4 105 53.3 1193 72.6 Public, No Universal Coverage 28 4.7 42 8.5 67 19.8 67 34.0 208 12.7
Mainly Private 2 0.3 10 2.0 197 58.3 25 12.7 235 14.3
Only Private 1 0.2 2 0.4 5 1.5 0 0.0 8 0.5
Total 596 100.0 493 100.0 338 100.0 197 100.0 1644 100.0 ICU after transplant
Different ICUs 427 94.5 371 87,5 254 88.8 139 87,4 1214 89.9
Same ICUs, different staffs 25 5.5 53 12.5 32 11.2 20 12.6 137 10.1
* *
Total 452 100.0 424 100.0 286 100.0 159 100.0 1351 100.0
aAnalysis performed only in the subgroup of Transplant Area
Region rates for each variables were compared one against each other. All comparisons resulted significant at the α level =0,05. Not significant differences are indicated by markers at the bottom,
Table S2. Subanalysis of geographic areas for the 2 nations with the largest number of answers ITALY
red zone ITALY orange
zone
USA East Coast
states
USA West Coast
states
Stop Transplants No. % No. % No. % No. %
Not at all 42 42.9 27 30.0 8 18.6 4 11.1
Selectively 52 53.0 60 66.7 35 81.4 32 89.9
Completely 4 4.1 3 3.3 0 0.0 0 0.0
* * ° °
There were 412 not classified answers for Italy and 159 for USA
Geographic rates were compared one against each other; differences resulted not significant at the α level= .05
Table S3. Stratification according to Specialty
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TRANSPLANT
AREA COVID-19
AREA Ethicist Other Total
No. % No. % No. % No. % No. %
Region
Italy 302 30.4 221 50.0 33 44.6 43 32.3 599 36.5
Europe 379 38.2 69 15.6 19 25.7 31 23.3 498 30.3
Americas 196 19.8 101 22.9 16 21.6 32 24.1 345 21.0
Asia Africa Oceania 115 11.6 51 11.5 6 8.1 27 20.3 199 12.1
* *
Total 992 100.0 442 100.0 74 100.0 133 100.0 1641 100.0 Experience level
Trainee 98 10.0 41 9.4 13 18.3 19 26.4 171 10.9
Appointed 390 39.7 190 43.5 36 50.7 34 47.2 650 41.6
Head of Team 495 50.3 206 47.1 22 30.9 19 26.3 742 47.5
* * ° °
Total 983 100.0 437 100.0 71 100.0 72 100.0 1563 100.0 Stop Transplants
Not at all 168 17.9 97 23.3 26 44.1 22 13.3 313 19.8
Selectively 679 72.1 283 68.0 32 54.2 125 75.7 1119 70.8
Completely 94 10.0 36 8.7 1 1.7 18 10.9 149 9.4
*° * °
Total 941 100.0 416 100.0 59 100.0 165 100.0 1581 100.0 Equity resources distribution
Strongly agree 290 34.7 105 33.4 5 9.8 19 37.3 419 33.5
Partially agree 391 46.8 159 50.6 32 62.7 28 54.9 610 48.8
Partially disagree 115 13.8 37 11.8 10 19.6 3 5.9 165 13.2
Strongly disagree 39 4.7 13 4.1 4 7.8 1 2.0 57 4.6
Total 835 100.0 314 100.0 51 100.0 51 100.0 1251 100.0 Living Related Transplants
In urgent cases 489 58.4 218 65.1 35 68.6 51 63.0 793 60.8
In al scheduled cases 60 7.2 29 8.7 11 21.6 10 12.3 110 8.4
Never 289 34.5 88 26.3 5 9.8 20 24.7 402 30.8
* ° ° *
Total 838 100.0 335 100.0 51 100.0 81 100.0 1305 100.0 Health System
Public, Universal Coverage 747 75.1 302 67.7 52 70.2 91 71.6 1192 72.6 Public, No Universal Coverage 120 12.1 55 12.3 11 14.9 22 17.3 208 12.7
Mainly Private 121 12.2 88 19.7 11 14.9 13 10.2 233 14.2
Only Private 6 0.6 1 0.2 0 0.0 1 0.8 8 0.5
* *° °
Total 994 100.0 446 100.0 74 100.0 127 100.0 1641 100.0 ICU after transplant
Different ICUs 795 90.4 309 90.4 46 88.5 63 81.8 1213 89.9
Same ICUs, but different staff 84 9.6 33 9.6 6 11.5 14 18.2 137 10.1 Total 879 100.0 342 100.0 52 100.0 77 100.0 1350 100.0 Position rates for each variables were compared one against each other. All comparisons resulted significant at the α level =0,05. Not significant differences are indicated by markers at the bottom.
Subanalysis according to Organ of Interest
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Liver Liver or
Kidney Kidney
Kidney-Pancreas Cardiothoracic Nontransplantt surgeon Total
Region No. % No. % No. % No. % No. % No. %
Italy 87 28.1 55 32.9 68 29.6 30 32.3 8 36.4 248 30.2
Europe 106 34.2 56 33.5 117 50.9 42 45.2 5 22.7 326 39.7
Americas 68 21.9 40 24.0 31 13.5 17 18.3 1 4.5 157 19.1
Asia, Australia, Africa 49 15.8 16 9.6 14 6.1 4 4.3 8 36.4 91 11.1
* *° *
Total 310 100.0 167 100.0 230 100.0 93 100.0 22 100.0 822 100.0 Experience level
Trainee 29 9.4 23 13.9 21 9.3 3 3.2 4 18.2 80 9.8
Appointed 136 44.0 56 33.7 83 36.7 35 37.6 12 54.5 322 39.5
Head of Team 144 46.6 87 52.4 122 54.0 55 59.1 6 27.3 414 50.7
* *° °
Total 309 100.0 166 100.0 226 100.0 93 100.0 22 100.0 816 100.0 Stop Transplants
Not at all 58 19.3 32 20.0 23 10.6 24 26.4 2 10.0 139 17.6
Selectively 228 76.0 118 73.8 151 69.3 65 71.4 16 80.0 578 73.3
Completely 14 4.7 10 6.3 44 20.2 2 2.2 2 10.0 72 9.1
* *
Total 300 100.0 160 100.0 218 100.0 91 100.0 20 100.0 789 100.0 Equity resources distribuition
Strongly agree 82 30.3 46 32.6 96 50.5 22 26.8 6 31.6 252 35.8
Partially agree 139 51.3 68 48.2 75 39.5 36 43.9 7 36.8 325 46.2
Partially disagree 35 12.9 21 14.9 14 7.4 20 24.4 5 26.3 95 13.5
Strongly disagree 15 5.5 6 4.3 5 2.6 4 4.9 1 5.3 31 4.4
* *
Total 271 100.0 141 100.0 190 100.0 82 100.0 19 100.0 703 100.0 Living Related Transplants
In urgent cases 178 65.4 84 57.1 98 48.3 42 64.6 11 61.1 413 58.6
In al scheduled cases 20 7.4 14 9.5 12 5.9 2 3.1 3 16.7 51 7.2
Never 74 27.2 49 33.3 93 45.8 21 32.3 4 22.2 241 34.2
*° * °
Total 272 100.0 147 100.0 203 100.0 65 100.0 18 100.0 705 100.0 Health System
Public, Universal Coverage 230 74.0 119 71.3 189 82.2 72 77.4 16 72.7 626 76.1 Public, No Universal Coverage 41 13.2 19 11.4 26 11.3 9 9.7 5 22.7 100 12.2
Mainly Private 37 11.9 28 16.8 14 6.1 12 12.9 1 4.5 92 11.2
Only Private 3 1.0 1 0.6 1 0.4 0 0.0 0 0.0 5 0.6
*° * § ° §
Total 311 100.0 167 100.0 230 100.0 93 100.0 22 100.0 823 100.0 ICU after transplant
Different ICUs 255 90.1 139 93.3 182 89.2 78 91.8 20 100.0 674 91.0 Same ICUs, but different staff 28 9.9 10 6.7 22 10.8 7 8.2 0 0.0 67 9.0
*° § °^ *§^
Total 283 100.0 149 100.0 204 100.0 85 100.0 20 100.0 741 100.0 Organ of interest rates for each variables were compared one against each other. All comparisons resulted significant at the α level =0·05. Not significant differences are indicated by markers at the bottom.
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Table S5. Thematic analysis of reasons for responsesMaster Theme Sub-themes Quotes Exemplifying Meaning Factors influencing
how respondents explain their decisions about whether or not resource allocation in COVID-19 meets principles of equity in healthcare
Normalizing Inequity Temporary storm
Resource scarcity
Moral distress
‘The pandemic issue is potentially very serious, but it will change
’ ‘Big impact on health system because of the simultaneous number of cases infected.
The collapse of ICUs available will have an important impact on distributing resources to first solve this situation’
‘Worry that general care in our patients who have a high risk of dying when they will not receive a new organ’
Political Stewardship Preparedness
Legitimacy of resourcing decisions Alternative models of shifting practice
‘Problem is to design a system with the possibility to answer to acute phases’
‘Too many local interest are politically influencing the distribution of resources’
‘COVID- 19 is critical but leaving ‘clean’
centres for transplant critical patients is important too’
Collateral Damage Maximizing benefit (polarized between saving the most lives and saving the most life years)
Resolving ethical dilemmas
‘The needs of the many outweigh the needs of the few’
‘Deaths in waiting list are as bad as deaths in COVID-19. SOT is available as effective treatment and must be offered’
‘COVID-19 is a pandemic which has baffled everyone but should not be at the cost of patients suffering from other diseases which also need care and attention’
