Effects of patient compliance, parental education and race on nephrologists' recommendations for kidney transplantation in children

Preparing for kidney replacement therapy in pediatric advanced CKD: a review of literature and defining a multi-disciplinary clinical approach to patient-caregiver education

Pediatric patients with progressive chronic kidney disease (CKD) approaching kidney replacement therapy (KRT) make up a small population but carry significant morbidity and mortality. Patients and caregivers require comprehensive kidney failure education to ensure a smooth start to KRT. Choice of KRT modality can be influenced by medical comorbidities, patient/caregiver comprehension, and comfort with a particular modality, social and economic factors, and/or implicit bias of the health care team. As KRT modality can influence morbidity, mortality, and quality of life, we created a pediatric advanced CKD clinic to provide comprehensive KRT education and to promote informed decision-making for our advanced CKD patients and their caregivers.

Systematic review of health policy and behavioral economics: A neglected point in health promotion

BACKGROUND

Health policymakers use a variety of policy tools. These policies are either based on external factors or are based on paternal considerations; people may need to have help in the selection of items that may be regretted about them in the future. However, recent research on behavioral economics shows that major decision-making mistakes are not only limited to vulnerable groups but also are ubiquitous and systematic. The purpose of this study was on health policy making with a behavioral economics approach in health promotion.

MATERIALS AND METHODS

The eligible studies were obtained from Medline (PubMed), Web of Science, and Scopus databases. The search strategy uses a combination of keywords in the titles. The keywords of behavioral economics along with the keyword of health have been used to find related articles.

RESULTS

After deleting duplicate articles, a total of 38 articles were identified. After reviewing the title and abstract, 13 studies were omitted because they did not meet the inclusion criteria. Ten articles were removed from the found articles due to the unavailability of the full text and four articles were excluded because their method was quantitative. Finally, a total of 11 articles were eligible for including this review study.

CONCLUSION

Recent research on behavioral economics shows that decision-making errors are not limited to vulnerable groups but are ubiquitous and systematic. Forgotten income or negligible income is very high and is reasonably explained by transaction costs. Educational interventions often have little effect and do not benefit from basic cost-benefit tests. In addition, the seemingly insignificant aspects of choice-frameworks and assumptions-often have a profound effect on behavior.

Gender, Racial, and Ethnic Differences in the Utilization of Cervical Disk Replacement for Cervical Radiculopathy

INTRODUCTION

Cervical radiculopathy (CR) is commonly treated by spine surgeons, with surgical options including anterior cervical diskectomy and fusion (ACDF) and cervical disk replacement (CDR). CDR is a motion-sparing alternative to ACDF and was approved by the US FDA in 2007. CDR utilization has increased because evidence has emerged demonstrating its long-term efficacy. Despite CDR's efficacy, studies have suggested that socioeconomic factors may influence which patients undergo CDR versus ACDF. Our objective was to determine whether gender, racial, and ethnic disparities exist in the utilization of CDR versus ACDF for CR.

METHODS

Patients age ≥18 years undergoing elective CDR or ACDF for CR between 2017 and 2020 were identified in the Vizient Clinical Database. Proportions of patients undergoing CDR and ACDF, as well as their comorbidities, complications, and outcomes, were compared by sex, race, and ethnicity. Bonferroni correction was done for multiple comparisons.

RESULTS

A total of 7,384 patients, including 1,427 undergoing CDR and 5,957 undergoing ACDF, were reviewed. Black patients undergoing surgical treatment of CR were less likely to undergo CDR than ACDF, had a longer length of stay, and had higher readmission rates, while Hispanic patients had higher complication rates than non-Hispanic patients.

DISCUSSION

Important racial and ethnic disparities exist in CR treatment. Interventions are necessary to ensure equal access to spine care by reducing barriers, such as underinsurance and implicit bias.

LEVEL OF EVIDENCE

IV (Case Series).

Providers and Families Weigh in on Delays to Pediatric Kidney Transplant Wait-List Activation

INTRODUCTION

Timely access to kidney transplant is essential to reducing mortality of children with kidney disease. We examined factors affecting providers' decisions to delay waitlisting, compared perceptions of important factors of providers to families, when delaying activation, and describe recommendations to improve support for pediatric patients and families to overcome waitlisting delays.

METHODS

Using a mixed-methods design, 20 providers and 20 families of pediatric patients with kidney disease, participated in interviews and surveys. Interviews were analyzed using thematic analysis. Surveys were analyzed with descriptive statistics.

RESULTS

Avoiding retransplantation, treatment nonadherence, poor psychological readiness for transplant, poor physical health, and greater need for social support were the key themes affecting providers' decisions to delay waitlisting. At least 70% of both providers and families felt that waitlisting should be delayed until patients and families had reliable access to transportation, mental health support, and caregivers who can better understand medical information. At least 70% of families surveyed felt it was important to delay waitlisting until they had regulated blood pressure and well-managed labs. Ethical concerns emerge that waitlisting practices may contribute to disparities in access to transplant.

CONCLUSION

Providers and families agree that stabilizing the family situation and improving adherence to treatment are important reasons to delay waitlisting. However, pediatric patients facing greater disparities need easier access to psychological services, strengthened social support, access to economic resources, and stronger relationships with coordinators. Addressing patient burdens is essential for reaching more equitable listing practices.

Racial Disparities in Pediatric Kidney Transplantation under the New Kidney Allocation System in the United States

BACKGROUND AND OBJECTIVES

In December 2014, the Kidney Allocation System (KAS) was implemented to improve equity in access to transplantation, but preliminary studies in children show mixed results. Thus, we aimed to assess how the 2014 KAS policy change affected racial and ethnic disparities in pediatric kidney transplantation access and related outcomes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed a retrospective cohort study of children <18 years of age active on the kidney transplant list from 2008 to 2019 using the Scientific Registry of Transplant Recipients. Log-logistic accelerated failure time models were used to determine the time from first activation on the transplant list and the time on dialysis to deceased donor transplant, each with KAS era or race and ethnicity as the exposure of interest. We used logistic regression to assess odds of delayed graft function. Log-rank tests assessed time to graft loss within racial and ethnic groups across KAS eras.

RESULTS

All children experienced longer wait times from activation to transplantation post-KAS. In univariable analysis, Black and Hispanic children and other children of color experienced longer times from activation to transplant compared with White children in both eras; this finding was largely attenuated after multivariable analysis (time ratio, 1.16; 95% confidence interval, 1.01 to 1.32; time ratio, 1.13; 95% confidence interval, 1.00 to 1.28; and time ratio, 1.17; 95% confidence interval, 0.96 to 1.41 post-KAS, respectively). Multivariable analysis also showed that racial and ethnic disparities in time from dialysis initiation to transplantation in the pre-KAS era were mitigated in the post-KAS era. There were no disparities in odds of delayed graft function. Black and Hispanic children experienced longer times with a functioning graft in the post-KAS era.

CONCLUSIONS

No racial and ethnic disparities from activation to deceased donor transplantation were seen before or after implementation of the KAS in multivariable analysis, whereas time on dialysis to transplantation and odds of short-term graft loss improved in equity after the implementation of the KAS, without compromising disparities in delayed graft function.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_12_07_CJN06740521.mp3.

Age and sex determine conversion from immediate-release to extended-release tacrolimus in a multi-center cohort of Canadian pediatric renal transplant recipients

ER-Tac, taken once per day, is associated with improved adherence. This study examined the potential patient and clinical factors that influence clinicians to convert pediatric patients from immediate-release to ER-Tac. This prospective multi-center observational study followed Canadian pediatric kidney transplant recipients up to 5 years post-transplant. Cox Proportional Hazards Regression was used to examine the influence of factors on conversion to ER-Tac. Sixty-six participants were included in this analysis. For every additional year of age at the time of transplant, the likelihood of conversion was more than doubled (HR 2.54, CI 1.83, 3.54, P < 0.001). The impact of age reduced by three percent for every month after transplant (HR 0.97, CI 0.95, 0.98, P < 0.001). Girls were more likely to be converted than boys (HR 3.78, CI 1.35, 10.6, P 0.01). Adherence measures (MAM-MM and tacrolimus trough variability), individual barriers to adherence, renal function, HLA mismatch, and rejection were not significant predictors of conversion in the final regression model. ER-Tac was preferentially prescribed to older age and female patients. Female sex and adolescence are both associated with worse graft outcomes, but we found no link between individualized markers of adherence/graft risk and conversion. Clinicians appeared to be using demographic features to distinguish patients at perceived higher risk and converted accordingly, without a case-by-case evaluation of who is more susceptible to poor outcomes.

Policy in pediatric nephrology: successes, failures, and the impact on disparities

Pediatric nephrology has a history rooted in pediatric advocacy and has made numerous contributions to child health policy affecting pediatric kidney diseases. Despite this progress, profound social disparities remain for marginalized and socially vulnerable children with kidney disease. Different risk factors, such as genetic predisposition, environmental factors, social risk factors, or health care access influence the emergence and progression of pediatric kidney disease, as well as access to life-saving interventions, leading to disparate outcomes. This review will summarize the breadth of literature on social determinants of health in children with kidney disease worldwide and highlight policy-based initiatives that mitigate the adverse social factors to generate greater equity in pediatric kidney disease.

An ethical analysis of obesity as a determinant of pediatric heart transplant candidacy

BACKGROUND

Inclusion of BMI as criterion in the determination of heart transplant candidacy in children is a clinical and ethical challenge. Childhood obesity is increasing and children with heart disease are not spared. Currently, many adult heart transplant centers consider class II obesity and higher (BMI > 35 kg/m² ) to be a relative contraindication for transplantation due to risk of poor outcome after transplant. No national guidelines exist regarding consideration of BMI in pediatric heart transplant and outcomes data are limited. This leaves decisions about transplant candidacy in obese pediatric patients to individual institutions or on a case-by-case basis, allowing for bias and inequity.

METHODS

We review (a) the prevalence of childhood obesity, including among heart transplant candidates, (b) the lack of existing BMI guidelines, and (c) relevant literature on BMI and pediatric heart transplant outcomes. We discuss the ethical considerations of using obesity as a criterion using the principles of utility, justice, and respect for persons.

RESULTS

Existing transplant outcomes data do not show that obese children have different or poor enough outcomes compared to non-obese children to warrant exclusion. Moreover, obesity in the United States is unequally distributed by race and socioeconomic status. Children already suffering from health disparities are therefore doubly penalized if obesity denies them access to life-saving transplant.

CONCLUSION

Insufficient data exist to support using any BMI cutoff as an absolute contraindication for heart transplant in children. Attention should be paid to health equity issues when considering excluding a patient for transplant based on obesity.

Communicating with diverse patients: How patient and clinician factors affect disparities

OBJECTIVE

Patient-clinician communication (PCC) may generate or reduce healthcare disparities. This paper is based on the 2017 International Conference on Communication in Healthcare keynote address and reviews PCC literature as a research area for the National Institute on Minority Health and Health Disparities (NIMHD).

METHODS

A narrative review of selected evidence on disparities in PCC experienced by race and ethnic minorities, associations between PCC and poor health outcomes, and patient and clinician factors related to PCC.

RESULTS

Factors associated with poor quality PCC on the patient level include being a member of racial/ethnic minority, having limited English proficiency, and low health and digital literacy; on the clinician level, being less culturally competent, lacking communication skills to facilitate shared decision-making, and holding unconscious biases. Recommendations include offering patient- and/or clinician-targeted interventions to guard against unconscious biases and improve PCC, screening patients for health literacy and English proficiency, integrating PCC in performance processes, and leveraging health information technologies to address unconscious biases.

CONCLUSION

EffectivePCC is a pathway to decrease health disparities and promote health equity.

PRACTICE IMPLICATIONS

Standardized collection of social determinants of health in the Electronic Health Record is an importantfirst step in promoting more effective PCC.

An overview of disparities and interventions in pediatric kidney transplantation worldwide

Despite the stated goals of the transplant community and the majority of organ allocation systems, persistent racial disparities in pediatric kidney transplantation exist throughout the world. These disparities are evident in both living and deceased donor kidney transplantation and are independent of any clinical differences between racial groups. The reasons for these persistent disparities are multifactorial, reflecting both patient and provider barriers to care. In this review, we examine the most current findings regarding disparities in pediatric kidney transplantation and consider interventions which may help reduce those disparities.

Explaining the Persistence of Health Disparities: Social Stratification and the Efficiency-Equity Trade-off in the Kidney Transplantation System

Why do health disparities persist when their previous mechanisms are eliminated? Fundamental-cause theorists argue that social position primarily improves health through two metamechanisms: better access to health information and technology. I argue that the general, cumulative, and embodied consequences of social stratification can produce another metamechanism: an efficiency-equity trade-off. A case in point is kidney transplantation, where the mechanisms previously thought to link race to outcomes--ability to pay and certain factors in the kidney allocation system--have been greatly reduced, yet large disparities persist. I show that these current disparities are rooted in factors that directly influence posttransplant success, placing efficiency and racial/ethnic equity at cross-purposes.

Do patient race and sex change surgeon recommendations for TKA?

BACKGROUND

Prior investigations have suggested that physician-related factors may contribute to differential use of TKA among women and ethnic minorities. We sought to evaluate the effect of surgeon bias on recommendations for TKA.

QUESTIONS/PURPOSE

Using an experimental approach with standardized patient scenarios, we sought to evaluate surgeon recommendations regarding TKA, specifically to determine whether recommendations for TKA are influenced by (1) patient race, and (2) patient sex.

METHODS

We developed four computerized scenarios for all combinations of race (white or black) and sex (male or female) for otherwise similar patients with end-stage knee osteoarthritis. Patients gave an orthopaedic history of 2 years worsening pain with decreased functional status and failure of oral antiinflammatory medications and corticosteroid intraarticular injections. Orthopaedic surgeons attending the 2012 annual meetings of the New York State Society of Orthopaedic Surgeons and American Association of Hip and Knee Surgeons were recruited for the study. Surgeons passing an open recruitment table at each meeting were asked to participate. Of the 1111 surgeons in attendance at either meeting, 113 (10.2%) participated in the study. All participants viewed the "control" patient's story (white male) and were randomized to view one of the three "experimental" scenarios (white female, black male, black female). After viewing each scenario, the participants were anonymously asked whether they would recommend TKA. An a priori power analysis showed that 112 participants were needed to detect a 15% difference in the likelihood of recommending surgery for white versus nonwhite patients in the test scenarios evaluated with 90% power at a level of significance of 0.05.

RESULTS

Of the 39 surgeons who viewed the white male plus black female scenario, there were 33 (85%) concordant responses (TKA offered to both patients) and six discordant responses (TKA offered to only one of the patients), with no effect of patient race and sex (p = 0.99). Of the 37 surgeons who viewed the white male plus black male scenario, there were 33 (89%) concordant responses and four discordant responses, with no effect of patient race (p = 0.32). Of the 37 surgeons who viewed the white male plus white female scenario, there were 30 (77%) concordant responses and seven discordant responses, with no effect of patient sex (p = 0.71).

CONCLUSION

After orthopaedic surgeons viewed video scenarios of patients with end-stage knee osteoarthritis, patient race and sex were not associated with a different likelihood of a surgical recommendation. Our findings support the notion that patient race and sex may be less influential on decision making when there are strong clinical data to support a decision. Physician bias may have a greater effect on decision making in situations where the indications for surgery are less clear.

Disparities, race/ethnicity and access to pediatric kidney transplantation

PURPOSE OF REVIEW

Kidney transplantation remains the optimal treatment for children with end-stage renal disease; yet, in the United States, profound differences in access to transplant persist, with black children experiencing significantly reduced access to transplant compared with white children. The reasons for these disparities remain poorly understood. Several recent studies provide new insights into the interplay of socioeconomic status, racial/ethnic disparities and access to pediatric kidney transplantation.

RECENT FINDINGS

New evidence suggests that disparities are more pronounced in access to living vs. deceased donors. National allocation policies have mitigated racial differences in pediatric deceased donor kidney transplant (DDKT) access after waitlisting. However, disparities in access to DDKT are stark for minority emerging adults, who lose pediatric priority allocation. Although absence of health insurance poses an important barrier to transplant, even after adjustment for insurance status and neighborhood poverty, disparities persist. Differential access to care and unjust social structures are posited as important modifiable barriers to achieving equity in pediatric transplant access.

SUMMARY

Future approaches to overcome disparities in pediatric kidney transplant access must focus on the continuum of the transplant process, including equitable health care access. Public health advocacy efforts to promote national policies that address disparate multilevel socioeconomic factors are essential.

Development of a measure of caregiver burden in paediatric chronic kidney disease: The Paediatric Renal Caregiver Burden Scale

To inform the development of a measure of caregiver burden for carers of children with chronic kidney disease, interviews were conducted with 16 caregivers and 10 renal healthcare professionals. A pool of 97 items generated from interviews was reduced to 60 items following review. A piloting exercise provided evidence for the usability, readability and relevance of items and informed further adaptations resulting in the 51-item Paediatric Renal Caregiver Burden Scale. Further to assessment of its psychometric properties, it is hoped that that the Paediatric Renal Caregiver Burden Scale will serve as a useful measure of caregiver burden in paediatric chronic kidney disease.

The start of the transplant journey: referral for pediatric solid organ transplantation

The focus of the majority of the psychosocial transplant literature is on post-transplant outcomes, but the transplant journey starts much earlier than this, at the point when transplantation is first considered and a referral for transplant evaluation is made. In this review, we cover information regarding the meaning of the referral process for solid organ transplantation. We discuss various factors of the referral for transplantation including the impact of referral on the pediatric patient and the family, potential expectations and misconceptions held by pediatric patients and parents, the role of health literacy, decision-making factors, and the informational needs of pediatric patients and parents. We elucidate steps that providers can take to enhance transplant referral and provide suggestions for much needed research within this area.

Transplantation at the nexus of behavioral economics and health care delivery

The transplant surgeon's decision to accept and utilize an organ typically is made within a constrained time window, explicitly cognizant of numerous health-related risks and under the potential influence of considerable regulatory and institutional pressures. This decision affects the health of two distinct populations, those patients receiving organ transplants and those waiting to receive a transplant; it also influences the physician's life and their institute's productivity. The numerous, at times nonaligned, incentives established by the complex clinical and regulatory environment, have been derived specifically to influence physicians' behaviors, and though well intended, may lead to responses that are nonoptimal when considering the myriad stakeholders being influenced. This may compromise the quality of care provided to the population at risk, and has potential to influence the physician-patient relationship. A synergistic collaboration between transplant physicians and economists that is focused on this decision environment may help to alleviate these strains. This viewpoint discusses behavioral economic principles and how they might be applied to transplantation. Specifically, the previous medical decision-making literature on transplantation will be reviewed and a discussion on how a behavioral model of physician decision making can be utilized will be explored. To date this approach has not been integrated into transplantation decision making.

Migration background and patient satisfaction in a pediatric nephrology outpatient clinic

BACKGROUND

We examined the association of a migration background and patient satisfaction in a pediatric nephrology outpatient clinic in Germany.

METHODS

This was a cross-sectional study of 348 families presenting at the Pediatric Nephrology Outpatient Department of Charité University Children's Hospital in Berlin during 2008. Parents were asked to complete a questionnaire containing basic sociodemographic information, a subjective categorical rating of disease severity and communication with the medical team, and a validated patient satisfaction score (ZUF-8) derived from a customer satisfaction score used by industry and modified for healthcare providers.

RESULTS

Of the 348 families included in the study, 131 patients (38 %) had a migration background (20 different nationalities, 22 different native languages). Patient satisfaction (rated on a scale from 8 to 40) was significantly higher in families without (32.9  ±  4.6) than in those with a migration background (30.8  ±  4.7; p < 0.0001). A multivariate linear regression analysis revealed that trust in doctors, friendliness of the doctor, severity of the child's disease, number of medications prescribed, and a migration background were significantly and independently correlated with patient satisfaction.

CONCLUSIONS

Migrant families were less satisfied with the provision of the outpatient care provided by our department than non-migrants.

Racial disparities in pediatric access to kidney transplantation: does socioeconomic status play a role?

Racial disparities persist in access to renal transplantation in the United States, but the degree to which patient and neighborhood socioeconomic status (SES) impacts racial disparities in deceased donor renal transplantation access has not been examined in the pediatric and adolescent end-stage renal disease (ESRD) population. We examined the interplay of race and SES in a population-based cohort of all incident pediatric ESRD patients <21 years from the United States Renal Data System from 2000 to 2008, followed through September 2009. Of 8452 patients included, 30.8% were black, 27.6% white-Hispanic, 44.3% female and 28.0% lived in poor neighborhoods. A total of 63.4% of the study population was placed on the waiting list and 32.5% received a deceased donor transplant. Racial disparities persisted in transplant even after adjustment for SES, where minorities were less likely to receive a transplant compared to whites, and this disparity was more pronounced among patients 18-20 years. Disparities in access to the waiting list were mitigated in Hispanic patients with private health insurance. Our study suggests that racial disparities in transplant access worsen as pediatric patients transition into young adulthood, and that SES does not explain all of the racial differences in access to kidney transplantation.

The role of unconscious bias in surgical safety and outcomes

Racial, ethnic, and gender disparities in health outcomes are a major challenge for the US health care system. Although the causes of these disparities are multifactorial, unconscious bias on the part of health care providers plays a role. Unconscious bias occurs when subconscious prejudicial beliefs about stereotypical individual attributes result in an automatic and unconscious reaction and/or behavior based on those beliefs. This article reviews the evidence in support of unconscious bias and resultant disparate health outcomes. Although unconscious bias cannot be entirely eliminated, acknowledging it, encouraging empathy, and understanding patients' sociocultural context promotes just, equitable, and compassionate care to all patients.

Once-daily tacrolimus extended-release formulation: 1 year after conversion in stable pediatric kidney transplant recipients

It is speculated that a once-daily dosage of immunosuppression can increase adherence and thereby graft survival. Until now, there have been no studies on once-daily use of Tacrolimus extended-release formulation (TAC-ER) in children following pediatric kidney transplantation. In 11 stable pediatric kidney recipients >10 years, efficacy, safety, and tolerability of a switch to TAC-ER were observed over one year. Adherence was determined by use of the BAASIS-Scale Interview and comparison of individual variability of Tacrolimus trough levels. Over the observation period, two acute rejections were observed in one girl with nonadherence and repeated Tacrolimus trough levels of 0 ng/m. Beside this, there were no acute rejections in this trial. TAC dose was increased in 3/11 patients and decreased in 2/11 patients within the course of the study. Six patients did not require a dose adjustment. All but one patient had a maximum of 1 dose change during therapy. Mean Tacrolimus dose, trough levels, and Glomerular filtration rates were also stable. Adherence, as measured by BAASIS-Scale Interview and coefficient of variation of Tacrolimus trough levels, was good at all times. It is concluded that conversion to Tac-ER is safe in low-risk children following pediatric kidney transplantation.

Sex, race, and socioeconomic disparities in kidney disease in children

Racial and gender differences in the prevalence and treatment of chronic kidney disease in US children have been reported. Girls have lower rates of kidney transplantation than boys. Incidence of end-stage renal disease is twice as high among black patients compared with whites. African Americans are less likely than white patients to achieve hemoglobin targets on dialysis, are more likely to be treated with hemodialysis, and to wait longer for a transplant. Reasons for these disparities in disease burden and treatment choices are not known, but possible causes include genetic factors and socioeconomic and sociocultural influences on accessing medical care.

A national conference to determine research priorities in pediatric solid organ transplantation

The need for evidence-based practice guidelines requires high quality, carefully controlled clinical research trials. This multidisciplinary conference attempted to: identify urgent clinical and research issues, identify obstacles to performing clinical trials, develop concepts for organ-specific and all-organ research and generate a report that would serve as a blueprint for future research initiatives. A few themes became evident. First, young children present a unique immunologic environment which may lead to tolerance, therefore, including young children in immunosuppression withdrawal and tolerance trials may increase the potential benefits of these studies. Second, adolescence poses significant barriers to successful transplantation. Non-adherence may be insufficient to explain poorer outcomes. More studies focused on identification and prevention of non-adherence, and the potential effects of puberty are required. Third, the relatively naive immune system of the child presents a unique opportunity to study primary infections and alloimmune responses. Finally, relatively small numbers of transplants performed in pediatric centers mandate multicenter collaboration. Investment in registries, tissue and DNA repositories will enhance productivity. The past decade has proven that outcomes after pediatric transplantation can be comparable to adults. The pediatric community now has the opportunity to design and complete studies that enhance outcomes for all transplant recipients.

Predictors of patient selection in bariatric surgery

OBJECTIVE

To identify sociodemographic and clinical predictors of patient selection in bariatric surgery.

SUMMARY BACKGROUND DATA

Population-based studies suggest that bariatric surgery patients are disproportionately privately insured, middle-aged white women. It is uncertain whether such disparities are due to surgeon decisions to operate, differences among morbidly obese individuals in access to surgery, or patients' personal preferences regarding surgical treatment.

METHODS

We conducted a national survey of 1343 U.S. bariatric surgeons. The questionnaire contained clinical vignettes generated using a balanced fractional factorial design. For each of 3 hypothetical patients unique in age, race, gender, body mass index (BMI), comorbidities, social support, functional status, and insurance, respondents were asked if they would operate. Logistic regression was used to determine the odds of selection for each characteristic while controlling for the other 7 characteristics. Subset analyses were also performed using combinations of BMI and comorbidities.

RESULTS

A total of 62.5% of eligible surgeons responded (n = 820). Patient race did not influence surgeon decisions to operate. Hypothetical patient age, BMI, and social support were most influential. In the subgroup of patients who did not meet current NIH BMI and comorbidity criteria for bariatric surgery, male sex (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.14-0.76) was associated with decreased odds of selection. Overall, younger age (OR, 0.09; 95% CI, 0.07-0.11), older age (OR, 0.70; 95% CI, 0.56-0.90), limited functional status (OR, 0.66; 95% CI, 0.52-0.82), poor social support (OR, 0.37; 95% CI, 0.30-0.47), self-pay (OR, 0.72; 95% CI, 0.57-0.91), and public insurance (OR, 0.54; 95% CI, 0.43-0.67) were associated with decreased odds of selection. BMI and comorbidity criteria influenced the magnitude of these effects.

CONCLUSIONS

Patient race did not play a role in surgeon decisions to operate. Further research should examine the roles of unequal access to bariatric surgery and differing socio-cultural perceptions of morbid obesity on racial disparities. The influence of patient age, gender, insurance status, social support, and functional status on decisions to operate was mitigated by BMI and comorbidities. Policy-makers currently debating BMI and comorbidity criteria for bariatric surgery should also consider guidelines pertaining to these sociodemographic issues that influence patient selection in bariatric surgery.

Short stature and growth hormone use in pediatric hemodialysis patients

End-stage renal disease (ESRD) causes growth retardation in children, and poor growth has been linked to worse outcomes. Recombinant human growth hormone (rhGH) can increase growth velocity and final adult height in pediatric ESRD patients. We aimed to identify clinical predictors of short stature (height standard deviation score (Ht SDS) <-1.88) and rhGH use in short stature pediatric hemodialysis patients. In 2002, the Centers for Medicare & Medicaid Services (CMS) Clinical Performances Measures (CPM) ESRD Project collected demographic, clinical and laboratory data as well as rhGH use on all in-center hemodialysis patients in the US aged <18 years. The odds ratios (OR) of short stature and rhGH use for individual predictors were determined by multivariate logistic regression modeling. Six-hundred and fifty-one (92%) of 710 eligible patients were included for analysis. Of these, 266 (41%) had Ht SDS <-1.88. After adjustment, short stature was predicted by congenital/urologic causes of ESRD ((OR 5.4; 95% confidence interval [CI], 2.1-13.8; p <0.001) in patients aged 10-14 years; (OR 2.8; 95% CI, 1.5-5.4; p <0.01) in patients aged 15-18 years) and increasing years on dialysis ((OR 1.2; 95% CI, 1.1-1.4; p <0.01) in patients aged 10-14 years; (OR 1.2; 95% CI, 1.1-1.4; p <0.001) in patients aged 15-18 years). Of 266 short stature patients, 214 (80.5%) had data on rhGH use. Of these, 80 (37%) had been prescribed rhGH. After adjustment, use of rhGH in short-stature patients was predicted by white race (OR 2.1; 95% CI, 1.1-4.0; p <0.05), increasing years on dialysis (OR 1.13; 95% CI, 1.05-1.22; p <0.01) and patients with BMI <16.6 kg/m(2) (OR 3.1; 95% CI, 1.2-8.4; p <0.05). Increasing age and level of intact parathyroid hormone were not associated with rhGH use among short stature patients. A significant proportion of pediatric hemodialysis patients have short stature. The majority of short-stature patients are not receiving rhGH. Patients with short stature who are white, have longer durations on dialysis and have lower BMI are more likely to receive rhGH.

Pediatric transplantation, 1994-2003

This article uses OPTN/SRTR data to review trends in pediatric transplantation over the last decade. In 2003, children younger than 18 made up 3% of the 82,885 candidates for organ transplantation and 7% of the 25,469 organ transplant recipients. Children accounted for 14% of the 6,455 deceased organ donors. Pediatric organ transplant recipients differ from their adult counterparts in several important aspects, including the underlying etiology of organ failure, the complexity of the surgical procedures, the pharmacokinetic properties of common immunosuppressants, the immune response following transplantation, the number and degree of comorbid conditions, and the susceptibility to post-transplant complications, especially infectious diseases. Specialized pediatric organ transplant programs have been developed to address these special problems. The transplant community has responded to the particular needs of children and has provided them special consideration in the allocation of deceased donor organs. As a result of these programs and protocols, children are now frequently the most successful recipients of organ transplantation; their outcomes following kidney, liver, and heart transplantation rank among the best. This article demonstrates that substantial improvement is needed in several areas: adolescent outcomes, outcomes following intestine transplants, and waiting list mortality among pediatric heart and lung candidates.

Non-compliance in children post-liver transplant. Who are the culprits?

Although non-compliance in pediatric liver transplants is known to be a major cause of late graft loss and patient mortality, follow-up seems inconsistent. As liver transplant becomes a luxury because of the shortage of organs, the need to maximize graft and patient survival by intense monitoring becomes a necessity. When evaluating children with elevated liver enzymes post-transplant, early or late non-compliance should always be suspected. The risk of non-compliance in children with chronic illness varies from 10 to 89%. In a study by Sudan et al. non-compliance was one of the leading causes of late mortality in children age 10-17 yr. Although it is well documented that teenagers have a high rate of non-compliance, the rate in the younger children has not been documented. In our series, we found that parental non-compliance comprises the majority of our problems with liver dysfunction, hospitalization, and graft loss. The purpose of this study was to evaluate the incidence of non-compliance in children post-liver transplant. A retrospective chart review of patient records from admissions and outpatient records was performed for documentation of elevated enzymes and low immunosuppressive levels. From July 1987 to December 2002, our program performed 266 liver transplants in 234 children, with 1-yr graft survival of 84% and 1-yr patient survival of 90%. Our overall patient survival was 85% with 77% graft survival. There were 40 children with documented non-compliance with mild to severe liver dysfunction in this study. Twenty-eight of these children were younger than 10 yr [28 of 40 (46%) <5 yr], and 12 (30%) were older than 10 yr at the time of rejection. In 10 of 40 children, there was one documented incident of non-compliance, while 26 of 40 had two to four incidents, and four had five or more documented events. Our children (50%) came from two-parent households. The remaining 50% were from single households. In 27 of 40 (68%) children, rejection was confirmed by liver biopsy. In children on cyclosporine (Neoral; Novartis, East Hanover, NJ, USA) with a known history of non-compliance and low immunosuppressive levels, C2 monitoring was performed to verify absorption. Admission for drug monitoring and verification of non-compliance was accomplished in 32 of 40 (80%). Four of the 40 children (10%) were retransplanted, and one child had died. In conclusion, non-adherence to medications remains a major source of graft loss and morbidity post-transplant. We found that non-compliance crosses all socio-economic and cultural groups and that flexibility of clinic hours, shortened time between visits, and decreased numbers and times of medication will increase adherence.

Noncompliance with immunosuppressive medications in pediatric and adolescent patients receiving solid-organ transplants

Advances in knowledge in transplantation have improved 1-year renal allograft survival in all age groups of pediatric patients. However, the results from many studies have shown that the long-term allograft survival is least successful in adolescent recipients. The major cause of late graft failure in adolescents can be contributed in large measure to medication noncompliance. Medication noncompliance in teenagers has been shown to be more than four times greater in adolescents than in adults. The teenage years are a time of transition from childhood to adulthood. Important tasks during this transition include the development of an autonomous identity that progresses to full independence. However, the cognitive skills and intellectual maturation of adolescents are still limited, and this is particularly true in adolescents with chronic diseases. They have difficulty with abstract thinking, particularly the conceptualization of future consequences of present actions. This leads to characteristic risk-taking behaviors, including noncompliance with medical treatments. This transition is more intricate for adolescents with chronic illness because of their physical limitations. There are a number of strategies that are helpful in mitigating noncompliance. Adolescents must be dealt with directly. Previous noncompliant behaviors need to be acknowledged and dealt with, because studies show that noncompliance is a "stable" personality attribute that persists over time. Efforts should be made to choose medications that have the least side effects. Psychological and psychiatric conditions such as posttraumatic stress disorder require early recognition, diagnosis, and treatment. It is necessary to build rapport with teenagers, and this should start before transplantation. A multidisciplinary approach with physicians, social workers, nurses, and transplant coordinators is an effective mean of enhancing compliance. These and other strategies outlined in this discussion will enable the adolescent to achieve good compliance rates and prevent graft loss.

Pediatric transplantation

Analysis of the OPTN/SRTR database demonstrates that, in 2002, pediatric recipients accounted for 7% of all recipients, while pediatric individuals accounted for 14% of deceased organ donors. For children fortunate enough to receive a transplant, there has been continued improvement in outcomes following all forms of transplantation. Current 1-year graft survival is generally excellent, with survival rates following transplantation in many cases equaling or exceeding those of all other recipients. In renal transplantation, despite excellent early graft survival, there is evidence that long-term graft survival for adolescent recipients is well below that of other recipients. A causative role for noncompliance is possible. While the significant improvements in graft and patient survival are laudable, waiting list mortality remains excessive. Pediatric candidates awaiting liver, intestine, and thoracic transplantation face mortality rates generally greater than those of their adult counterparts. This finding is particularly pronounced in patients aged 5 years and younger. While mortality awaiting transplantation is an important consideration in refining organ allocation strategies, it is important to realize that other issues, in addition to mortality, are critical for children. Consideration of the impact of end-stage organ disease on growth and development is often equally important, both while awaiting and after transplantation.