Pre-transplant evaluation completion for Black/African American renal patients: Two theoretical frameworks

Dialysis Social Workers' Perspectives on Barriers and Facilitators to Kidney Transplantation

INTRODUCTION

Dialysis social workers are integral in the transplant evaluation process; however, research on dialysis social workers' perspectives on access to kidney transplantation is limited. Methods: A mixed methods study examining dialysis social workers' perspectives on transplant barriers and facilitators. Dialysis social workers completed online surveys and participated in virtual, semi-structured interviews. Qualitative data were recorded, transcribed, and analyzed using thematic analysis. Quantitative data were analyzed descriptively. Results: Twenty-seven dialysis social workers completed surveys, and 15 participated in qualitative interviews. Participants were predominantly female (93%) and White (89%). While the majority (67%) had practiced as a social worker for 6+ years, most had ≤5 years of dialysis experience (52%). The majority described the transplant referral process as somewhat easy (67%) and rated their relationship with transplant programs as either fair or good (78%). Both survey and interview data identified similar patient-level barriers, such as lack of social support and obesity. Interviews further elucidated organizational and system level barriers including tensions between dialysis and transplant centers, transplant center accessibility, and systemic discrimination. Identified facilitators included patient motivation, transplant center communication, and transplant resources. Conclusion: Dialysis social workers provided a unique perspective on barriers and facilitators to kidney transplantation. While barriers to transplant were often considered at the patient level, organizational and system level factors were crucial to understanding transplant access. These findings could inform future efforts between dialysis and transplant centers to improve access to kidney transplantation.

Disentangling Dialysis Facility and Transplant Center Factors on Evaluation Start Following Referral for Kidney Transplantation: A Regional Study in the United States

Rationale & Objective

Little is known about the relative importance of dialysis facilities and transplant centers on variability in starting an evaluation among patients referred for kidney transplant. The primary objective of this study was to leverage cross-classified multilevel modeling to simultaneously examine the contextual effects of dialysis facilities and transplant centers on variation in the start of the transplant evaluation process.

Study Design

Retrospective cohort study.

Setting & Participants

Dialysis patients referred for kidney transplant to transplant centers across the Southeast, Northeast, New York, or Ohio River Valley US regions from January 1, 2012, to December 31, 2020, were identified from the United States Renal Data System and the Early Steps to Transplant Access Registry and followed through June 30, 2021. A total of N=25,488 referred patients were nested with 1,720 dialysis facilities and 26 transplant centers.

Outcomes

Starting an evaluation for kidney transplant at a transplant center within 6 months of referral.

Analytical Approach

A series of multilevel models were performed to estimate the variability in starting an evaluation for kidney transplant within 6 months of referral. The between-dialysis facility and/or transplant center variation in starting an evaluation was quantified using the median OR.

Results

Among 25,488 dialysis patients referred for kidney transplantation, 51% of patients started an evaluation at a transplant center within 6 months of referral. In multilevel models, the median OR between transplant centers was higher (indicating higher unexplained variability) than the dialysis facility median OR, regardless of measured patient, dialysis facility, and transplant center characteristics.

Limitations

Early transplant access data was limited to 20 of 48 transplant centers across these 4 regions.

Conclusions

When taking dialysis facilities and transplant centers into account, variation in starting an evaluation for kidney transplant appeared at both the dialysis facility and transplant center-level but was more apparent among transplant centers.

Disparities in pathways to reduction mammaplasty: A single institution review of 425 women with macromastia

BACKGROUND

Reduction mammaplasty improves the quality of life by providing functional and aesthetic benefits to women with macromastia. This study contributes to the existing literature on socioeconomic and clinical barriers to referral for plastic surgery procedures by focusing specifically on reduction mammaplasty.

METHODS

Patients with macromastia were identified via a chart review in a single institution from 2021-2022. The treatment pathway for each patient was characterized by reception of referral, completion of plastic surgery consultation, and eventual reception of surgery. After controlling for clinical covariates, multivariate logistic regression was applied to quantify the independent impact of race, insurance, and language status on the completion of surgery (p < 0.05).

RESULTS

The final patient cohort included 425 women with macromastia. Among the 151 patients who were first seen by a primary care physician, 64 (42%) completed an initial plastic surgery consultation. Among all patients, 160 (38%) eventually underwent reduction mammaplasty. Multivariate regression predictions indicated a lower likelihood of completing breast reduction surgery in patients with current smoking history (OR: 0.08, 95% CI: 0.01-0.59) and higher body mass index (BMI) (OR: 0.94, 95% CI: 0.90-0.97) (p < 0.05). Minority race and ethnicity, private insurance status, and primary language status were not significant predictors of this outcome (p > 0.05).

CONCLUSIONS

In this study, the socioeconomic variables were not independent predictors of breast reduction surgery completion. However, the association of minority race and ethnicity and nonprivate insurance status with the most common reasons for breast reduction deferral suggest an indirect influence of socioeconomic status on the treatment pathway.

The Use of Kidneys With Lower Longevity From Deceased Donors to Improve Access to Preemptive Renal Transplantation for Elderly Patients: A Qualitative Study

Background

There is a gap between the number of patients waiting for a transplant and the number of kidneys available. Some deceased donor kidneys are currently nonutilized, as medical teams fear that they will experience suboptimal graft survival. However, these organs could provide an acceptable therapeutic option if they were allocated for preemptive kidney transplantation in elderly candidates.

Objective

This project aims to gather patients' perspectives on the allocation of kidneys with lower longevity for preemptive kidney transplantation in elderly patients.

Design

Individual interviews.

Setting

The Center hospitalier de l'Université de Montréal (CHUM) chronic kidney disease (CKD) clinic.

Participants

Patients aged between 64 and 75 years with CKD G4-5 ND, followed at the CHUM and who have not initiated dialysis yet.

Methods

Between March and July 2023, we conducted 14 individual interviews with patients aged between 64 and 75 years who had CKD G4-5 ND and were followed at the CHUM. The interviews were digitally recorded and transcribed. Thematic analysis was conducted.

Results

Most participants were in favor of using kidneys with lower longevity to increase their access to transplantation, improve their quality of life, enable accelerated transplantation, and avoid dialysis. Patients also wanted to be engaged in the decision-making process, underlining the importance of informed consent. Although the use of kidneys with lower longevity offers the hope of returning to "normal" life, some patients were concerned about the risk of reduced graft survival and the need for a subsequent kidney transplant. In these cases, patients were interested in using mitigation strategies, such as prioritization for kidney transplantation from standard donors in case of early graft loss associated with receiving kidneys with lower longevity. They also recommended the development of a separate waiting list for patients consenting to preemptive transplantation with kidneys with lower longevity.

Limitations

This study was conducted in only 1 nephrology clinic in the province of Quebec with French-speaking patients. Consequently, the results may not be generalizable to other populations, including ethnic minorities.

Conclusion

The use of kidneys with lower longevity for preemptive kidney transplantation appears to be an interesting option for elderly kidney transplant candidates. However, patient information and participation in the decision-making process are essential. Moreover, organ donation organizations and transplant programs should develop a separate waitlist for transplant candidates who have preconsented to receive organ offers of deceased donor kidneys with lower longevity.

Trial registration

Not registered.

A systematic review of psychosocial and sex-based contributors to gender disparities in the United States across the steps towards kidney transplantation

INTRODUCTION

Persistent findings suggest women and patients identified as "female" are less likely to receive a kidney transplant. Furthermore, the limited research on transplantation among transgender and gender diverse people suggests this population is susceptible to many of the same psychosocial and systemic barriers.

OBJECTIVE

This review sought to 1) highlight terminology used to elucidate gender disparities, 2) identify barriers present along the steps to transplantation, and 3) summarize contributors to gender disparities across the steps to transplantation.

METHODS

A systematic review of gender and sex disparities in the steps towards kidney transplantation was conducted in accordance with PRISMA guidelines across four social science and public health databases from 2005 to 23.

RESULTS

The search yielded 1696 initial results, 33 of which met inclusion criteria. A majority of studies followed a retrospective cohort design (n = 22, 66.7%), inconsistently used gender and sex related terminology (n = 21, 63.6%), and reported significant findings for gender and sex disparities within the steps towards transplantation (n = 28, 84.8%). Gender disparities among the earlier steps were characterized by patient-provider communication and perception of medical suitability whereas disparities in the later steps were characterized by differential outcomes based on older age, an above average BMI, and Black racial identity. Findings for transgender patients pointed to issues computing eGFR and the need for culturally tailored care.

DISCUSSION

Providers should be encouraged to critically examine the diagnostic criteria used to determine transplant eligibility and adopt practices that can be culturally tailored to meet the needs of patients.

Quantifying the association of individual-level characteristics with disparities in kidney transplant waitlist addition among people with HIV

BACKGROUND

Over 45% of people with HIV (PWH) in the United States at least 50 years old and are at heightened risk of aging-related comorbidities including end-stage kidney disease (ESKD), for which kidney transplant is the optimal treatment. Among ESKD patients, PWH have lower likelihood of waitlisting, a requisite step in the transplant process, than individuals without HIV. It is unknown what proportion of the inequity by HIV status can be explained by demographics, medical characteristics, substance use history, and geography.

METHODS

The United States Renal Data System, a national database of all individuals ESKD, was used to create a cohort of people with and without HIV through Medicare claims linkage (2007-2017). The primary outcome was waitlisting. Inverse odds ratio weighting was conducted to assess what proportion of the disparity by HIV status could be explained by individual characteristics.

RESULTS

Six thousand two hundred and fifty PWH were significantly younger at ESKD diagnosis and more commonly Black with fewer comorbidities. PWH were more frequently characterized as using tobacco, alcohol and drugs. Positive HIV-status was associated with 57% lower likelihood of waitlisting [adjusted hazard ratio (aHR): 0.43, 95% confidence interval (CI): 0.46-0.48, P  < 0.001]. Controlling for demographics, medical characteristics, substance use and geography explained 39.8% of this observed disparity (aHR: 0.69, 95% CI: 0.59-0.79, P  < 0.001).

CONCLUSION

PWH were significantly less likely to be waitlisted, and 60.2% of that disparity remained unexplained. HIV characteristics such as CD4 + counts, viral loads, antiretroviral therapy adherence, as well as patient preferences and provider decision-making warrant further study.

Systems Connected to Inequities in Access to Kidney Transplantation and the Value of Intersectionality

Patients from minoritized backgrounds based on race/ethnicity, gender, sexuality, and other social identities are more likely to experience inequities in access in kidney transplantation. Although these inequities have been reported over the decades, limited research focuses on the experiences of patients with intersecting minoritized social statuses and the mechanisms that contribute to their reduced access to transplantation. Intersectionality, a framework for understanding the ways in which multiple social identities represent interacting systems of oppression and privilege, offers a nuanced approach for understanding the experiences of patients diagnosed with end-stage organ disease with intersecting social identities. This article outlines complex systems that perpetuate inequities by highlighting the value of intersectionality in studying disparate outcomes to transplant and providing recommendations for the transplant community. This article aligns with the ESOT call for action to promote equity in transplantation worldwide.

Understanding people's decisions when choosing or declining a kidney transplant: a qualitative evidence synthesis

OBJECTIVES

To synthesise qualitative research exploring patients' perspectives, experiences and factors influencing their decision-making preferences when choosing or declining kidney transplantation.

DESIGN

A qualitative evidence synthesis.

DATA SOURCES

Electronic databases were searched from 2000 to June 2021: PubMed, MEDLINE, CINAHL, Embase, PsycINFO, Web of Science, ProQuest Core Databases for Dissertations and Theses, and Google Scholar.

ELIGIBILITY CRITERIA

Qualitative studies exploring and reporting decision-making preferences of people with kidney disease, which reported influencing factors when choosing or declining kidney transplantation, published in English from high-income and middle-income countries.

DATA EXTRACTION AND SYNTHESIS

Titles were screened against the inclusion criteria. Thematic synthesis was done with the use of the Critical Appraisal Skills Programme qualitative checklist to assess study quality, and assessment of confidence in the qualitative findings was done using the Grading of Recommendation, Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative Research.

FINDINGS

37 studies from 11 countries reported the perspectives of 1366 patients with kidney disease. Six descriptive themes were developed: decisional preferences influenced patients' readiness to pursue kidney transplantation, gathering sufficient information to support decision-making, navigating the kidney transplant assessment pathway, desire for kidney transplantation, opposed to kidney transplantation and uncertainties while waiting for the kidney transplant. A new enhanced theoretical model was developed to aid understanding of the complexities of decision-making in people with kidney disease, by integrating the Theory of Planned Behaviour and the Adaptive Decision Maker Framework to incorporate the novel findings.

CONCLUSION

The synthesis provides a better understanding of the extremely complex decision-making processes of people with kidney disease, which are aligned to their kidney transplantation preferences. Further research is needed to better understand the reasons for declining kidney transplantation, and to underpin development of personalised information, interventions and support for patients to make informed decisions when presented with kidney replacement options.

PROSPERO REGISTRATION NUMBER

CRD42021272588.

Multicenter study of racial and ethnic inequities in liver transplantation evaluation: Understanding mechanisms and identifying solutions

Racial and ethnic disparities persist in access to the liver transplantation (LT) waiting list; however, there is limited knowledge about underlying system-level factors that may be responsible for these disparities. Given the complex nature of LT candidate evaluation, a human factors and systems engineering approach may provide insights. We recruited participants from the LT teams (coordinators, advanced practice providers, physicians, social workers, dieticians, pharmacists, leadership) at two major LT centers. From December 2020 to July 2021, we performed ethnographic observations (participant-patient appointments, committee meetings) and semistructured interviews (N = 54 interviews, 49 observation hours). Based on findings from this multicenter, multimethod qualitative study combined with the Systems Engineering Initiative for Patient Safety 2.0 (a human factors and systems engineering model for health care), we created a conceptual framework describing how transplant work system characteristics and other external factors may improve equity in the LT evaluation process. Participant perceptions about listing disparities described external factors (e.g., structural racism, ambiguous national guidelines, national quality metrics) that permeate the LT evaluation process. Mechanisms identified included minimal transplant team diversity, implicit bias, and interpersonal racism. A lack of resources was a common theme, such as social workers, transportation assistance, non-English-language materials, and time (e.g., more time for education for patients with health literacy concerns). Because of the minimal data collection or center feedback about disparities, participants felt uncomfortable with and unadaptable to unwanted outcomes, which perpetuate disparities. We proposed transplant center-level solutions (i.e., including but not limited to training of staff on health equity) to modifiable barriers in the clinical work system that could help patient navigation, reduce disparities, and improve access to care. Our findings call for an urgent need for transplant centers, national societies, and policy makers to focus efforts on improving equity (tailored, patient-centered resources) using the science of human factors and systems engineering.

A scoping review of inequities in access to organ transplant in the United States

BACKGROUND

Organ transplant is the preferred treatment for end-stage organ disease, yet the majority of patients with end-stage organ disease are never placed on the transplant waiting list. Limited access to the transplant waiting list combined with the scarcity of the organ pool result in over 100,000 deaths annually in the United States. Patients face unique barriers to referral and acceptance for organ transplant based on social determinants of health, and patients from disenfranchised groups suffer from disproportionately lower rates of transplantation. Our objective was to review the literature describing disparities in access to organ transplantation based on social determinants of health to integrate the existing knowledge and guide future research.

METHODS

We conducted a scoping review of the literature reporting disparities in access to heart, lung, liver, pancreas and kidney transplantation based on social determinants of health (race, income, education, geography, insurance status, health literacy and engagement). Included studies were categorized based on steps along the transplant care continuum: referral for transplant, transplant evaluation and selection, living donor identification/evaluation, and waitlist outcomes.

RESULTS

Our search generated 16,643 studies, of which 227 were included in our final review. Of these, 34 focused on disparities in referral for transplantation among patients with chronic organ disease, 82 on transplant selection processes, 50 on living donors, and 61 on waitlist management. In total, 15 studies involved the thoracic organs (heart, lung), 209 involved the abdominal organs (kidney, liver, pancreas), and three involved multiple organs. Racial and ethnic minorities, women, and patients in lower socioeconomic status groups were less likely to be referred, evaluated, and added to the waiting list for organ transplant. The quality of the data describing these disparities across the transplant literature was variable and overwhelmingly focused on kidney transplant.

CONCLUSIONS

This review contextualizes the quality of the data, identifies seminal work by organ, and reports gaps in the literature where future research on disparities in organ transplantation should focus. Future work should investigate the association of social determinants of health with access to the organ transplant waiting list, with a focus on prospective analyses that assess interventions to improve health equity.

Kidney transplant candidates' and recipients' perspectives on the decision-making process to accept or refuse a deceased donor kidney offer: Trust and graft survival matter

BACKGROUND

The decision to accept a kidney from a deceased donor can be a difficult one. This study aims to capture the perspectives of transplant candidates (TCs) and kidney transplant recipients (KTRs) on the decision-making process when a deceased kidney is offered.

METHODS

We conducted six focus groups with KTRs and TCs. The content of the focus groups was analyzed using the qualitative thematic method.

RESULTS

KTRs reported that the experience of being offered a kidney could be difficult because of the circumstances of the offer and unpreparedness to participate in the discussion. Both KTRs and TCs trusted the medical expertise. Age and having experience with dialysis could influence the decision to accept an offer. In order to engage in the discussion, patients wanted to obtain estimates of expected graft survival. Patients did not express interest for a web-based calculator for patient use, but expected transplant physicians to summarize and explain the information that would impact graft survival time.

CONCLUSION

TCs and KTRs wanted to be involved in the decision to accept a deceased donor kidney. Tools that can help physicians communicate the risks and benefits of accepting an offer could improve patient participation in the decision-making process.

Non-medical barriers in access to early steps of kidney transplantation in the United States - A scoping review

BACKGROUND

In the United States (US), barriers in access to later steps in the kidney transplantation process (i.e. waitlisting) have been well documented. Barriers in access to earlier steps (i.e. referral and evaluation) are less well described due to the lack of national surveillance data. In this review, we summarize the available literature on non-medical barriers in access to kidney transplant referral and evaluation.

METHODS

Following PRISMA guidelines, we conducted a scoping review of the literature through June 3, 2021. We included all studies (quantitative and qualitative) reporting on barriers to kidney transplant referral and evaluation in the US published from 1990 onwards in English and among adult end-stage kidney disease (ESKD) patients (PROSPERO registration number: CRD42014015027). We narratively synthesized results across studies.

RESULTS

We retrieved information from 33 studies published from 1990 to 2021 (reporting data between 1990 and 2018). Most studies (n = 28, 85%) described barriers among patient populations, three (9%) among provider populations, and two (6%) included both patients and providers. Key barriers were identified across multiple levels and included patient- (e.g. demographic, socioeconomic, sociocultural, and knowledge), provider- (e.g. miscommunication, staff availability, provider perceptions and attitudes), and system- (e.g. geography, distance to care, healthcare logistics) level factors.

CONCLUSIONS

A multi-pronged approach (e.g. targeted and systemwide interventions, and policy change) implemented at multiple levels of the healthcare system will be necessary to reduce identified barriers in access to early kidney transplant steps. Collection of national surveillance data on these early kidney transplant steps is also needed to enhance our understanding of barriers to referral and evaluation.

Nonmedical barriers to early steps in kidney transplantation among underrepresented groups in the United States

PURPOSE OF REVIEW

Despite numerous targeted interventions and policy reforms, underrepresented minorities and patients with low socioeconomic status (SES) continue to have unequal access to kidney transplant. In this review, we summarize the most recent evidence on barriers to early kidney transplant steps (i.e. referral and evaluation) among underrepresented racial and ethnic minorities and low SES groups in the United States.

RECENT FINDINGS

This review highlights the interconnectedness of several patient-level (e.g. medical mistrust, transplant knowledge, access to care), provider-level (e.g. dialysis profit status, patient--provider communication; staff accessibility), and system-level (e.g. center-specific criteria, healthcare logistics, neighborhood poverty, healthcare logistics) factors associated with lower rates of referral and evaluation among underrepresented minorities and low SES groups, and the influence of systemic racism operating at all levels.

SUMMARY

Collection of national surveillance data on early transplant steps, as well as routinely captured data on upstream social determinants of health, including the measurement of racism rather than race, is necessary to enhance our understanding of barriers to referral and evaluation. A multipronged approach (e.g. targeted and systemwide interventions, and policy change) implemented at multiple levels of the healthcare system will be necessary to reduce disparities in early transplant steps.

Racial Disparities in Eligibility for Preemptive Waitlisting for Kidney Transplantation and Modification of eGFR Thresholds to Equalize Waitlist Time

BACKGROUND

Patients may accrue wait time for kidney transplantation when their eGFR is ≤20 ml/min. However, Black patients have faster progression of their kidney disease compared with White patients, which may lead to disparities in accruable time on the kidney transplant waitlist before dialysis initiation.

METHODS

We compared differences in accruable wait time and transplant preparation by CKD-EPI estimating equations in Chronic Renal Insufficiency Cohort participants, on the basis of estimates of kidney function by creatinine (eGFR_cr), cystatin C (eGFR_cys), or both (eGFR_cr-cys). We used Weibull accelerated failure time models to determine the association between race (non-Hispanic Black or non-Hispanic White) and time to ESKD from an eGFR of ≤20 ml/min per 1.73 m². We then estimated how much higher the eGFR threshold for waitlisting would be required to achieve equity in accruable preemptive wait time for the two groups.

RESULTS

By eGFR_cr, 444 CRIC participants were eligible for waitlist registration, but the potential time between eGFR ≤20 ml/min per 1.73 m² and ESKD was 32% shorter for Blacks versus Whites. By eGFR_cys, 435 participants were eligible, and Blacks had 35% shorter potential wait time compared with Whites. By the eGFR_cr-cys equation, 461 participants were eligible, and Blacks had a 31% shorter potential wait time than Whites. We estimated that registering Blacks on the waitlist as early as an eGFR of 24-25 ml/min per 1.73 m² might improve racial equity in accruable wait time before ESKD onset.

CONCLUSIONS

Policies allowing for waitlist registration at higher GFR levels for Black patients compared with White patients could theoretically attenuate disparities in accruable wait time and improve racial equity in transplant access.