Abstract
IMPORTANCE: Transfers of deceased organ donors from acute care hospitals to specialized donor care units (DCUs) offer operational and outcome advantages; however, current access to DCUs is limited and geographically uneven. Expanding access to DCUs may improve donation system efficiency. OBJECTIVE: To evaluate the geographic distribution of operating DCUs relative to acute care hospitals and explore how to most efficiently operationalize recommendations that a DCU operate in every donation region. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study analyzed deceased organ donor and hospital data captured in the Organ Procurement and Transplantation Network and American Hospital Association survey databases from January 1, 2018, to December 31, 2023. Acute-care hospitals and DCUs operating in the continental US and adult (aged ≥18 years) organ donors with brain death managed in acute care hospitals located in 2203 zip codes were included. The data analysis was performed between October 1, 2024, and December 1, 2025. EXPOSURES: Geographic location of organ donor hospitals. MAIN OUTCOMES AND MEASURES: The main outcome was the optimal number of DCUs required to enable transportation of all cohort donors from acute care hospitals to DCUs via ambulance (within a 180-minute drive). The number of additional DCUs needed to operationalize recommendations of a DCU in every donation region was quantified with and without consideration for donation service area boundaries using location-allocation modeling. RESULTS: Between 2018 and 2023, 53 093 deceased donors met the inclusion criteria (mean [SD] age, 44.3 years [15.0]; 60.0% male). Among the cohort, 61.9% of donors were managed in acute care hospitals within driving distance of 34 operating DCUs. In the current system with distinct donation service area boundaries, an additional 38 DCUs were estimated to provide plausible access to 92.7% of donors. If donation service area boundaries were ignored, 22 new DCUs were estimated to provide a referral facility for a larger proportion of donors (96.5%). CONCLUSIONS AND RELEVANCE: This cohort study found that despite their reported advantages and consensus endorsement, heterogeneous adoption of DCUs has left a substantial proportion of deceased donors after brain death more than a 180-minute drive from a DCU. Given inefficiencies introduced by donation service area boundaries, opening additional DCUs in acute care hospitals and donor transport across these existing boundaries may be 2 potential approaches to improve system efficiency and donation outcomes.