Abstract
In virtually every country, the need for organs for transplants far exceeds supply, leaving many patients to spend years waiting and even die before receiving a transplant. In the U.S. in 2009, for instance, where there are about 26 donors per million people, among candidates newly wait-listed for either a first or repeat kidney transplant the median wait time was 3.6 years (about one year for a liver transplant), and only slightly over 60% of individuals waitlisted ever received an organ. Approximately twenty individuals die each day because they cannot find a matching donor. In addition to the implications for transplant candidates, a kidney transplant, for example, also saves at least $200,000 over the life of the individual relative to on-going dialysis treatment.
Donation rates are even lower in Canada, with about 15 deceased donors per million people. In 2013, for example, there were 1,419 kidneys transplanted — 588 of which from living donors — but that left more than 3,000 Canadians on the waiting list for a new organ. Almost 42,000 Canadians were living with failing kidneys, creating an unprecedented demand for dialysis and transplants. During 2010, 229 patients died while waiting for organs. The end of that year saw 501 patients waiting for a liver, 135 for a heart, 310 for a lung and 98 for a pancreas.
There are many opportunities for individuals to express their intention to become an organ donor. In particular, when visiting public offices such as ServiceOntario for a variety of services (e.g., obtaining or renewing a driver’s license or health card), individuals have the opportunity to consent to be added to the organ donor registry when asked by a customer service representative (CSR). Similar procedures occur in the United States at the offices of the Department of Motor Vehicles (DMV). Yet, registration rates, although increased over the past few years, remain surprisingly low in Canada, at about 20-30%. These low donor registration rates are especially frustrating and surprising in light of the fact that an overwhelming majority of Canadians support organ donation – in Ontario in particular, 85% of citizens are in favour of organ donation.
With an aging population, advances in medical knowledge and technologies that make transplants an increasingly applicable option for many patients, and a growing ethnic heterogeneity that requires a more diverse composition of the organ supply, the imbalance between demand and supply is bound to increase, thus exacerbating individual, social and economic costs that could be avoided if more people behaved consistently with their beliefs and donated their organs.
The objective of this research is to apply concepts and methods from social and behavioural science to understand how registration rates can be increased, thus providing a larger base of potential donors to address the organ supply shortage and improve health and living prospects of thousands of Canadians and their families.
Previously, ServiceOntario and the Trillium Gift of Life Network partnership with academics explored whether low registration rates may be due in part to the length and complexity of registration forms or the timing when those forms are handed out. Moreover, these partners also tested interventions leveraging emotional and perspective-taking appeals, and discovered that these minor changes to the organ donor registration forms can significantly increase the rate with which Ontarians sign-up as organ donors.
In this proposal, we take a new but complementary perspective, focused on the customer service representatives who help Ontarians register using the forms. We ask whether and how the performance of customer service representatives at ServiceOntario offices, who are instructed to ask each customer whether they would like to register their consent to become organ donors (a “prompted choice” approach), can be improved.
Our interventions will consist of providing information to each CSR about his or her organ donor registration rate, with and without a comparison with that of the rest of ServiceOntario CSRs' conversion rates, using historical data. The idea would be that learning that, for example, the majority of other CSRs more effectively register organ donations might encourage a CSR to be more consistent in asking customers about their willingness to register and thereby improve their personal effectiveness. The information provided will not affect any actual evaluation of the CSRs; their relative effectiveness in terms of “conversion rates” of customers into donors will not be used for any formal performance evaluation, promotion or salary determination. Also, CSRs’ relative effectiveness is disclosed only to them individually but not to their peers.
The proposed interventions are based on the hypothesis that simply providing information about relative effectiveness, even when it has no impact on economic outcomes for an individual (i.e., compensation or promotion), will still have an impact by appealing to other, non-monetary forms of motivation (e.g., one’s self-image). If effective, this and similar interventions may represent simple, cost-effective ways to motivate CSRs, and are likely to be applicable to other contexts where relative effectiveness and activities with a pro-social component are present.
Scholars have performed similar behavioral investigations to study, for example, whether the (over)prescribing behavior or physicians is affected by providing aggregate statistics of the behavior of peers (http://jamanetwork.com/journals/jama/fullarticle/2488307); and whether information about one student's as well as other students' absence rate helps reducing excess absenteeism at school (http://scholar.harvard.edu/files/todd_rogers/files/influential_third_parties.pdf).