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Mathur AK, Goodrich N, Hong B, Smith AR, Mandell RJ, Warren PH, Gifford KA, Ojo AO, Merion RM. Use of Federal Reimbursement for Living Donor Costs by Racial and Ethnic Minorities: Implications for Disparities in Access to Living Donor Transplantation. Transplantation 2024:00007890-990000000-00758. [PMID: 38771064 DOI: 10.1097/tp.0000000000005013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Minority race, ethnicity, and financial barriers are associated with lower rates of living donor (LD) kidney transplantation (LDKT). Financial reimbursement for LD costs may impact social determinants of health and, therefore, impact disparities in access to LDKT. METHODS Among US LDKTs, we studied associations between racial and ethnic minority status and utilization of the National Living Donor Assistance Center (NLDAC), a means-tested reimbursement program for nonmedical LD costs. We analyzed demographic, clinical, income, and survey data from NLDAC and the Scientific Registry of Transplant Recipients (January 1, 2011, to December 31, 2022) to identify predictors of NLDAC utilization. RESULTS Among 70 069 US LDKTs, 6093 NLDAC applicants were identified (9% of US LDKTs). Racial and ethnic minorities were over-represented in NLDAC-supported LDKTs compared with non-NLDAC US LDKTs (Black donors 12% versus 9%; Black recipients 15% versus 12%; Hispanic donors 21% versus 14%; Hispanic recipients 23% versus 15%; all P < 0.001). Among preemptive transplants, use of NLDAC by donors to Hispanic recipients (11%) was nearly twice as high as that of non-Hispanic recipients (6%) (P < 0.001). At time of NLDAC application, 72% stated NLDAC "will make it possible" to donate; higher proportions of minority applicants agreed (Black 80%, White 70%, P < 0.001; Hispanic 79%, non-Hispanic 70%, P < 0.001). Racial and ethnic minority-concordant transplants were significantly more likely to use NLDAC (donor/recipient: Black/Black risk-adjusted odds ratio [OR], 1.85, other/other OR 2.59, Hispanic/Hispanic OR 1.53; all P < 0.05). CONCLUSIONS Reduction of LD financial barriers may increase access to LDKT, particularly in racial and ethnic minority communities.
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Affiliation(s)
- Amit K Mathur
- Division of Transplant Surgery, Mayo Clinic in Arizona, Phoenix, AZ
| | | | - Barry Hong
- Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Abigail R Smith
- Arbor Research Collaborative for Health, Ann Arbor, MI
- Division of Biostatistics, Department of Preventative Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Polireddy K, Crepeau RL, Matar AJ. Eliminating financial disincentives to living kidney donation - a call to action. Front Med (Lausanne) 2023; 10:1061342. [PMID: 37457572 PMCID: PMC10347391 DOI: 10.3389/fmed.2023.1061342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 06/09/2023] [Indexed: 07/18/2023] Open
Abstract
The incidence of end stage renal disease (ESRD) in the United States (US) is increasing each year. The lone curative treatment for ESRD remains kidney transplantation. Despite the demonstrated medical and economic benefits, living donor kidney transplantation (LDKT) only accounts for a small number of kidney transplantations each year. Direct and indirect costs exist that disincentivize potential living kidney donors from coming forward, such as the cost of travel and lodging, risk of death, potential loss of income due to an extended recovery time, and the inability to donate to a relative in the future if needed. Herein, we advocate for policy changes that make living kidney donation (LKD) a financially neutral process thereby incentivizing increased LDKT and mitigating the kidney donor shortage.
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Affiliation(s)
| | - Rebecca L. Crepeau
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Abraham J. Matar
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States
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Kaplan A, Rosenblatt R, Samstein B, Brown RS. Can Living Donor Liver Transplantation in the United States Reach Its Potential? Liver Transpl 2021; 27:1644-1652. [PMID: 34174025 DOI: 10.1002/lt.26220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 06/04/2021] [Accepted: 06/21/2021] [Indexed: 12/12/2022]
Abstract
Living donor liver transplantation (LDLT) is a vital tool to address the growing organ shortage in the United States caused by increasing numbers of patients diagnosed with end-stage liver disease. LDLT still only makes up a very small proportion of all liver transplantations performed each year, but there are many innovations taking place in the field that may increase its acceptance among both transplant programs and patients. These innovations include ways to improve access to LDLT, such as through nondirected donation, paired exchange, transplant chains, transplant of ABO-incompatible donors, and transplants in patients with high Model for End-Stage Liver Disease scores. Surgical innovations, such as laparoscopic donor hepatectomy, robotic hepatectomy, and portal flow modulation, are also increasingly being implemented. Policy changes, including decreasing the financial burden associated with LDLT, may make it a more feasible option for a wider range of patients. Lastly, center-level behavior, such as ensuring surgical expertise and providing culturally competent education, will help toward LDLT expansion. Although it is challenging to know which of these innovations will take hold, we are already seeing LDLT numbers improve within the past 2 years.
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Affiliation(s)
- Alyson Kaplan
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell School of Medicine, New York Presbyterian, New York, NY
| | - Russell Rosenblatt
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell School of Medicine, New York Presbyterian, New York, NY
| | - Benjamin Samstein
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell School of Medicine, New York Presbyterian, New York, NY
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell School of Medicine, New York Presbyterian, New York, NY
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Ross LF, Thistlethwaite JR. Gender and race/ethnicity differences in living kidney donor demographics: Preference or disparity? Transplant Rev (Orlando) 2021; 35:100614. [PMID: 33857733 PMCID: PMC8627424 DOI: 10.1016/j.trre.2021.100614] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/03/2021] [Accepted: 04/05/2021] [Indexed: 11/25/2022]
Abstract
In the United States, women are over-represented and Blacks are under-represented as living kidney donors. A traditional bioethics approach would state that as long as living donors believe that the benefits of participation outweigh the risks and harms (beneficence) and they give a voluntary and informed consent, then the demographics reflect a mere difference in preferences. Such an analysis, however, ignores the social, economic and cultural determinants as well as various forms of structural discrimination (e.g., racism, sexism) that may imply that the distribution is less voluntary than may appear initially. The distribution also raises justice concerns regarding the fair recruitment and selection of living donors. We examine the differences in living kidney donor demographics using a vulnerabilities analysis and argue that these gender and racial differences may not reflect mere preferences, but rather, serious justice concerns that need to be addressed at both the individual and systems level.
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Affiliation(s)
- Lainie Friedman Ross
- Carolyn and Matthew Bucksbaum Professor of Clinical Ethics, Professor of Pediatrics, Medicine, Surgery and the College, Associate Director of the MacLean Center for Clinical Medical Ethics, Co-Director of the Institute for Translational Medicine, University of Chicago, United States of America.
| | - J Richard Thistlethwaite
- Professor Emeritus of Surgery, Section on Transplantation Surgery, Faculty Emeritus of the MacLean Center for Clinical Medical Ethics, University of Chicago, United States of America
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5
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Abstract
Kidney transplantation is the ideal treatment option for patients with end-stage kidney disease (ESKD). Since there is clear mortality benefit to receiving a transplant regardless of comorbidities and age, the gold standard of care should focus on attaining kidney transplantation and minimizing, or better yet eliminating, time on dialysis. Unfortunately, only a small percentage of patients with ESKD receive a kidney transplant. Several barriers to kidney transplantation have been identified. Barriers can largely be grouped into three categories: patient-related, physician/provider-related, and system-related. Several barriers fall into multiple categories and play a role at various levels within the healthcare system. Acknowledging and understanding these barriers will allow transplant centers and dialysis facilities to make the necessary interventions to mitigate these disparities, optimize the transplant evaluation process, and improve patient outcomes. This review will discuss these barriers and potential interventions to increase access to kidney transplantation.
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6
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Siddique AB, Apte V, Fry-Revere S, Jin Y, Koizumi N. The impact of country reimbursement programmes on living kidney donations. BMJ Glob Health 2020; 5:bmjgh-2020-002596. [PMID: 32792408 PMCID: PMC7430320 DOI: 10.1136/bmjgh-2020-002596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Living-donor kidney transplantation is the gold standard treatment for patients with end-stage kidney disease. However, potential donors ubiquitously face financial as well as logistical barriers. To remove these disincentives from living kidney donations, the governments of 23 countries have implemented reimbursement programmes that shift the burdens of non-medical costs from donors to the governments or private entities. However, scientific evidence for the effectiveness of these programmes is scarce. The present study investigates whether these reimbursement programmes designed to ease the financial and logistical barriers succeeded in increasing the number of living kidney donations at the country level. The study examined within-country variations in the timing of such reimbursement programmes. METHOD The study applied the difference-in-difference (two-way panel fixed-effect) technique on the Poisson distribution to estimate the effects of these reimbursement programmes on a 17 year long (2000-2016) dataset covering 109 countries where living donor kidney transplants were performed. RESULTS The results indicated that reimbursement programmes have a statistically significant positive effect. Overall, the model predicted that reimbursement programmes increased country-level donation numbers by a factor of 1.12-1.16. CONCLUSION Reimbursement programmes may be an effective approach to alleviate the kidney shortage worldwide. Further analysis is warranted on the type of reimbursement programmes and the ethical dimension of each type of such programmes.
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Affiliation(s)
- Abu Bakkar Siddique
- Schar School of Policy and Government, George Mason University-Arlington Campus, Arlington, Virginia, USA
| | - Vandana Apte
- Department of Agricultural, Food and Resource Economics, Rutgers University, New Brunswick, New Jersey, USA
| | - Sigrid Fry-Revere
- Independent Bioethics Scholar, Washington, District of Columbia, USA
| | - Yanhong Jin
- Department of Agricultural, Food and Resource Economics, Rutgers University, New Brunswick, New Jersey, USA
| | - Naoru Koizumi
- Schar School of Policy and Government, George Mason University-Arlington Campus, Arlington, Virginia, USA
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7
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Bastani B. The present and future of transplant organ shortage: some potential remedies. J Nephrol 2019; 33:277-288. [PMID: 31399908 DOI: 10.1007/s40620-019-00634-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/30/2019] [Indexed: 12/24/2022]
Abstract
Transplantation remains the modality of choice for patients with end stage renal disease (ESRD). However, while there has been a steady rise in the number of patients with ESRD the supply of donors (combine living and deceased) has fallen far behind the need, resulting in an increasing number of qualified patients remaining on the wait-list, and thousands being removed from the list every year because of death or becoming too sick for transplantation. This has also fed to transplant tourism around the world. Several countries have implemented a variety of policies to overcome their organ shortage that are presented in this article. There is an urgent need for developing policies geared to the cultural norms of different societies and universally accepted ethical principles to remedy this public health issue.
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Affiliation(s)
- Bahar Bastani
- Division of Nephrology, Saint Louis University Hospital, Saint Louis University School of Medicine, 3635 Vista Avenue, Saint Louis, MO, 63110, USA.
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8
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McCormick F, Held PJ, Chertow GM, Peters TG, Roberts JP. Removing Disincentives to Kidney Donation: A Quantitative Analysis. J Am Soc Nephrol 2019; 30:1349-1357. [PMID: 31345987 DOI: 10.1681/asn.2019030242] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
| | - Philip J Held
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Thomas G Peters
- Department of Surgery, University of Florida, Jacksonville, Florida; and
| | - John P Roberts
- Department of Surgery, University of California, San Francisco, San Francisco, California
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10
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Platz TT, Siersbæk N, Østerdal LP. Ethically Acceptable Compensation for Living Donations of Organs, Tissues, and Cells: An Unexploited Potential? APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2019; 17:1-14. [PMID: 30143995 DOI: 10.1007/s40258-018-0421-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The number of living donations of human organs, tissues, and cells falls far short of the need. Market-like arrangements to increase donation rates have been proposed, but they are broadly considered unacceptable due to ethical concerns and are therefore not policy relevant in most countries. The purpose of this paper is to explore a different approach to increasing living donations, namely through the use of ethically acceptable compensation of donors. We review the compensation practices in Europe and find a lack of reimbursement of incurred costs and lack of compensation for non-monetary losses, which create disincentives for donation. We draw on a well-known philosophical theory to explain why donors are rarely fully compensated and why many existing proposals to raise donation rates are seen as controversial or even unethical. We present and discuss three categories of compensation with the potential to increase donation rates in an ethically acceptable way.
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Affiliation(s)
- Trine Tornøe Platz
- Department of Economics, Copenhagen Business School, Porcelænshaven 16A, 2000, Frederiksberg, Denmark.
| | - Nikolaj Siersbæk
- Department of Business and Economics, University of Southern Denmark, Campusvej 55, 5230, Odense, Denmark
| | - Lars Peter Østerdal
- Department of Economics, Copenhagen Business School, Porcelænshaven 16A, 2000, Frederiksberg, Denmark
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11
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Querido S, Weigert A, Adragão T, Machado D, Pais D. Rewards to increase living kidney donation: The state of the art. Nefrologia 2018; 39:11-14. [PMID: 30391020 DOI: 10.1016/j.nefro.2018.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/25/2018] [Indexed: 10/28/2022] Open
Affiliation(s)
- Sara Querido
- Department of Nephrology, Centro Hospitalar de Lisboa Ocidental - Hospital Santa Cruz, Carnaxide, Portugal.
| | - André Weigert
- Department of Nephrology, Centro Hospitalar de Lisboa Ocidental - Hospital Santa Cruz, Carnaxide, Portugal; Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Teresa Adragão
- Department of Nephrology, Centro Hospitalar de Lisboa Ocidental - Hospital Santa Cruz, Carnaxide, Portugal
| | - Domingos Machado
- Department of Nephrology, Centro Hospitalar de Lisboa Ocidental - Hospital Santa Cruz, Carnaxide, Portugal
| | - Diogo Pais
- Nova Medical School, Faculdade de Ciências Médicas - Universidade Nova de Lisboa, Lisbon, Portugal
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12
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Socioeconomic Status in Non-directed and Voucher-based Living Kidney Donation. Eur Urol Focus 2018; 4:185-189. [PMID: 30122635 DOI: 10.1016/j.euf.2018.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 07/01/2018] [Accepted: 07/13/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Little has been reported about the socioeconomic status (SES) and demographics of non-directed (altruistic) and voucher-based donation. OBJECTIVE To analyze common characteristics amongst altruistic donors in order to promote non-directed and voucher-based donation. DESIGN, SETTING, AND PARTICIPANTS Information regarding altruistic donations from 2008 to 2015 and voucher-based donors was obtained from the National Kidney Registry. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS An SES index, created and validated by the Agency for Healthcare Research and Quality (AHRQ), was created by geocoding the donor's zip code and linking it to seven publicly available SES variables found in the 2010 United States Census data. RESULTS AND LIMITATIONS In total, 267 non-directed and 3 voucher-based donations were identified. Non-directed donors were predominantly female (58%), with an average age of 45.6 yr (range, 21-72). The mean SES index score was 55.6 (SD=3.2), which corresponds to the 77th percentile of 1.5 million MediCare beneficiaries as reported by the AHRQ in 2008. Voucher-based donors were Caucasian males of high SES. The study was limited by the number of voucher-based donations. CONCLUSIONS Non-directed and voucher-based donors are in the upper end of the economic spectrum. The voucher-based program has built within it the inherent capacity to remove disincentives to donation, which currently limit altruistic donation. PATIENT SUMMARY We wanted to determine what types of people donated their kidneys altruistically, so that we could understand how to motivate more people to donate their kidneys. The voucher-based program was recently started and is a promising tool to motivate many people to donate kidneys by removing major disincentives to donation.
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Schold JD, Poggio ED, Augustine JJ. Gathering Clues to Explain the Stagnation in Living Donor Kidney Transplantation in the United States. Am J Kidney Dis 2018; 71:608-610. [PMID: 29685212 DOI: 10.1053/j.ajkd.2018.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 01/14/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH.
| | - Emilio D Poggio
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH; Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Joshua J Augustine
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH; Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH; Louis Stokes Veterans Administration Hospital, Cleveland, OH
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15
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Thiessen C, Jaji Z, Joyce M, Zimbrean P, Reese P, Gordon EJ, Kulkarni S. Opting out: a single-centre pilot study assessing the reasons for and the psychosocial impact of withdrawing from living kidney donor evaluation. JOURNAL OF MEDICAL ETHICS 2017; 43:756-761. [PMID: 28258071 DOI: 10.1136/medethics-2016-103512] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 11/15/2016] [Accepted: 02/03/2017] [Indexed: 06/06/2023]
Abstract
Understanding why individuals opt out of living donation is crucial to enhancing protections for all living donors and to identify modifiable barriers to donation. We developed an ethical approach to conducting research on individuals who opted out of living kidney donation and applied it in a small-scale qualitative study at one US transplant centre. The seven study participants (64% response rate) had varied reasons for opting out, the most prominent of which was concern about the financial burden from lost wages during the postoperative period. Several reported feeling alone during their decision-making process. Although no participants used an alibi, a centre-provided statement of non-eligibility to donate, all believed that centres should offer alibis to help preserve donor autonomy. Given the complexity of participants' decisions and the emotions they experienced before and after deciding not to donate, we suggest approaches for independent living donor advocates to support this population. This study demonstrates that research on individuals who opt out of donation is feasible and yields valuable insight into methods to improve the evaluation experience for potential living donors.
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Affiliation(s)
- Carrie Thiessen
- Department of Surgery, Section of Organ Transplantation and Immunology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Zainab Jaji
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael Joyce
- Department of Surgery, Section of Organ Transplantation and Immunology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Paula Zimbrean
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Peter Reese
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elisa J Gordon
- Department of Surgery, Comprehensive Transplant Center, Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sanjay Kulkarni
- Department of Surgery, Section of Organ Transplantation and Immunology, Yale School of Medicine, New Haven, Connecticut, USA
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Lentine KL, Kasiske BL, Levey AS, Adams PL, Alberú J, Bakr MA, Gallon L, Garvey CA, Guleria S, Li PKT, Segev DL, Taler SJ, Tanabe K, Wright L, Zeier MG, Cheung M, Garg AX. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation 2017; 101:S1-S109. [PMID: 28742762 PMCID: PMC5540357 DOI: 10.1097/tp.0000000000001769] [Citation(s) in RCA: 194] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 03/20/2017] [Indexed: 12/17/2022]
Abstract
The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors is intended to assist medical professionals who evaluate living kidney donor candidates and provide care before, during and after donation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach and guideline recommendations are based on systematic reviews of relevant studies that included critical appraisal of the quality of the evidence and the strength of recommendations. However, many recommendations, for which there was no evidence or no systematic search for evidence was undertaken by the Evidence Review Team, were issued as ungraded expert opinion recommendations. The guideline work group concluded that a comprehensive approach to risk assessment should replace decisions based on assessments of single risk factors in isolation. Original data analyses were undertaken to produce a "proof-in-concept" risk-prediction model for kidney failure to support a framework for quantitative risk assessment in the donor candidate evaluation and defensible shared decision making. This framework is grounded in the simultaneous consideration of each candidate's profile of demographic and health characteristics. The processes and framework for the donor candidate evaluation are presented, along with recommendations for optimal care before, during, and after donation. Limitations of the evidence are discussed, especially regarding the lack of definitive prospective studies and clinical outcome trials. Suggestions for future research, including the need for continued refinement of long-term risk prediction and novel approaches to estimating donation-attributable risks, are also provided.In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Living Kidney Donor Work Group. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017;101(Suppl 8S):S1-S109.
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Affiliation(s)
| | | | | | | | - Josefina Alberú
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | | | | | - Dorry L. Segev
- Johns Hopkins University, School of Medicine, Baltimore, MD
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Rodrigue JR, Fleishman A. Health Insurance Trends in United States Living Kidney Donors (2004 to 2015). Am J Transplant 2016; 16:3504-3511. [PMID: 27088263 PMCID: PMC5069113 DOI: 10.1111/ajt.13827] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 03/25/2016] [Accepted: 04/11/2016] [Indexed: 01/25/2023]
Abstract
Some transplant programs consider the lack of health insurance as a contraindication to living kidney donation. Still, prior studies have shown that many adults are uninsured at time of donation. We extend the study of donor health insurance status over a longer time period and examine associations between insurance status and relevant sociodemographic and health characteristics. We queried the United Network for Organ Sharing/Organ Procurement and Transplantation Network registry for all living kidney donors (LKDs) between July 2004 and July 2015. Of the 53 724 LKDs with known health insurance status, 8306 (16%) were uninsured at the time of donation. Younger (18 to 34 years old), male, minority, unemployed, less educated, unmarried LKDs and those who were smokers and normotensive were more likely to not have health insurance at the time of donation. Compared to those with no health risk factors (i.e. obesity, smoking, hypertension, estimated glomerular filtration rate <60, proteinuria) (14%), LKDs with 1 (18%) or ≥2 (21%) health risk factors at the time of donation were more likely to be uninsured (p < 0.0001). Among those with ≥2 health risk factors, blacks (28%) and Hispanics (27%) had higher likelihood of being uninsured compared to whites (19%; p < 0.001). Study findings underscore the importance of providing health insurance benefits to all previous and future LKDs.
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Affiliation(s)
- James R. Rodrigue
- Center for Transplant Outcomes and Quality Improvement, Transplant Institute, Beth Israel Deaconess Medical Center, Boston, MA,Departments of Surgery and Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Aaron Fleishman
- Center for Transplant Outcomes and Quality Improvement, Transplant Institute, Beth Israel Deaconess Medical Center, Boston, MA
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Abstract
Organ availability for transplantation has become an increasingly complex and difficult question in health economics and ethical practice. Advances in technology have seen prolonged life expectancy, and the global push for organs creates an ever-expanding gap between supply and demand, and a significant cost in bridging that gap. This article will examine the ethical implications for the nursing profession in regard to the procurement of organs from an impoverished seller’s market, also known as ‘Transplant Tourism’. This ethical dilemma concerns itself with resource allocation, informed consent and the concepts of egalitarianism and libertarianism. Transplant Tourism is an unacceptable trespass against human dignity and rights from both a nursing and collective viewpoint. Currently, the Australian Nursing and Midwifery Council, the Royal college of Nursing Australia, The Royal College of Nursing (UK) and the American Nurses Association do not have position statements on transplant tourism, and this diminishes us as a force for change. It diminishes our role as advocates for the most marginalised in our world to have access to care and to choice and excludes us from a very contemporary real debate about the mismatch of organ demand and supply in our own communities. As a profession, we must have a voice in health policy and human rights, and according to our Code of Ethics in Australia and around the world, act to promote and protect the fundamental human right to healthcare and dignity.
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Hays R, Rodrigue JR, Cohen D, Danovitch G, Matas A, Schold J, LaPointe Rudow D. Financial Neutrality for Living Organ Donors: Reasoning, Rationale, Definitions, and Implementation Strategies. Am J Transplant 2016; 16:1973-81. [PMID: 27037542 DOI: 10.1111/ajt.13813] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 03/13/2016] [Accepted: 03/19/2016] [Indexed: 01/25/2023]
Abstract
In the United States, live organ donation can be a costly and burdensome undertaking for donors. While most donation-related medical expenses are covered, many donors still face lost wages, travel expenses, incidentals, and potential for future insurability problems. Despite widespread consensus that live donors (LD) should not be responsible for the costs associated with donation, little has changed to alleviate financial burdens for LDs in the last decade. To achieve this goal, the transplant community must actively pursue strategies and policies to eliminate unreimbursed out-of-pocket costs to LDs. Costs should be more appropriately distributed across all stakeholders; this will also make live donation possible for people who, in the current system, cannot afford to proceed. We propose the goal of LD "financial neutrality," offer an operational definition to include the coverage/reimbursement of all medical, travel, and lodging costs, along with lost wages, related to the act of donating an organ, and guidance for consideration of medical care coverage, and wage and other expense reimbursement. The intent of this report is to provide a foundation to inform discussion within the transplant community and to advance initiatives for policy and resource allocation.
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Affiliation(s)
- R Hays
- Transplant Center, University of Wisconsin Hospital and Clinics, Madison, WI
| | - J R Rodrigue
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - D Cohen
- Department of Medicine, Columbia University Medical Center, New York, NY
| | - G Danovitch
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA
| | - A Matas
- Department of Surgery, University of Minnesota Medical Center-Fairview, Minneapolis, MN
| | - J Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - D LaPointe Rudow
- Recanati Miller Transplantation Institute, Mount Sinai Hospital, New York, NY
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Joshi S, Joshi S, Kupin W. Reciprocating living kidney donor generosity: tax credits, health insurance and an outcomes registry. Clin Kidney J 2015; 9:168-71. [PMID: 26798480 PMCID: PMC4720201 DOI: 10.1093/ckj/sfv123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 10/23/2015] [Indexed: 11/27/2022] Open
Abstract
Kidney transplantation significantly improves patient survival, and is the most cost effective renal replacement option compared with dialysis therapy. Living kidney donors provide a valuable societal gift, but face many formidable disincentive barriers that include not only short- and long-term health risks, but also concerns regarding financial expenditures and health insurance. Other than governmental coverage for their medical evaluation and surgical expenses, donors are often asked to personally bear a significant financial responsibility due to lost work wages and travel expenses. In order to alleviate this economic burden for donors, we advocate for the consideration of tax credits, lifelong health insurance coverage, and an outcomes registry as societal reciprocity to reward their altruistic act of kidney donation.
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Affiliation(s)
- Shivam Joshi
- Department ofMedicine, Jackson Memorial Hospital, Miami, FL, USA; Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Sheela Joshi
- Nova Southeastern University , Fort Lauderdale, FL , USA
| | - Warren Kupin
- Department ofMedicine, Jackson Memorial Hospital, Miami, FL, USA; Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
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A practical solution that bypasses the altruism versus incentives debate. Int Urol Nephrol 2015; 47:1515-7. [PMID: 26238944 DOI: 10.1007/s11255-015-1061-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 07/09/2015] [Indexed: 10/23/2022]
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Fisher JS, Butt Z, Friedewald J, Fry-Revere S, Hanneman J, Henderson ML, Ladin K, Mysel H, Preczewski L, Sherman LA, Thiessen C, Gordon EJ. Between Scylla and Charybdis: charting an ethical course for research into financial incentives for living kidney donation. Am J Transplant 2015; 15:1180-6. [PMID: 25833728 DOI: 10.1111/ajt.13234] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 12/15/2014] [Accepted: 12/25/2015] [Indexed: 01/25/2023]
Abstract
New approaches to address the kidney scarcity in the United States are urgently needed. The greatest potential source of kidneys is from living donors. Proposals to offer financial incentives to increase living kidney donation rates remain highly controversial. Despite repeated calls for a pilot study to assess the impact of financial compensation on living kidney donation rates, many fear that financial incentives will exploit vulnerable individuals and cast the field of transplantation in a negative public light, ultimately reducing donation rates. This paper provides an ethical justification for conducting a pilot study of a federally regulated approach to providing financial incentives to living kidney donors, with the goal of assessing donors' perceptions.
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Affiliation(s)
- J S Fisher
- Scripps Center for Organ and Cell Transplantation, Scripps Clinic/Green Hospital, La Jolla, CA
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23
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Quality and Quantity of Health Evaluation and the Follow-up of Iranian Living Donors. Transplant Proc 2015; 47:1092-5. [DOI: 10.1016/j.transproceed.2014.11.059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 11/19/2014] [Indexed: 01/13/2023]
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24
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The Rationale for Incentives for Living Donors: An International Perspective? CURRENT TRANSPLANTATION REPORTS 2015. [DOI: 10.1007/s40472-014-0045-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Tong A, Chapman JR, Wong G, Craig JC. Perspectives of Transplant Physicians and Surgeons on Reimbursement, Compensation, and Incentives for Living Kidney Donors. Am J Kidney Dis 2014; 64:622-32. [DOI: 10.1053/j.ajkd.2014.02.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 02/20/2014] [Indexed: 12/19/2022]
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Ríos A, López-Navas A, Ayala-García MA, Sebastián MJ, Abdo-Cuza A, Martínez-Alarcón L, Ramírez EJ, Muñoz G, Palacios G, Suárez-López J, Castellanos R, González B, Martínez MA, Díaz E, Ramírez P, Parrilla P. The attitude toward living kidney donation among personnel from units related to donation and transplantation in Spain, Mexico and Cuba. Ren Fail 2014; 36:489-94. [DOI: 10.3109/0886022x.2013.875814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Klarenbach S, Gill JS, Knoll G, Caulfield T, Boudville N, Prasad GVR, Karpinski M, Storsley L, Treleaven D, Arnold J, Cuerden M, Jacobs P, Garg AX. Economic consequences incurred by living kidney donors: a Canadian multi-center prospective study. Am J Transplant 2014; 14:916-22. [PMID: 24597854 PMCID: PMC4285205 DOI: 10.1111/ajt.12662] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 12/24/2013] [Accepted: 12/26/2013] [Indexed: 01/25/2023]
Abstract
Some living kidney donors incur economic consequences as a result of donation; however, these costs are poorly quantified. We developed a framework to comprehensively assess economic consequences from the donor perspective including out-of-pocket cost, lost wages and home productivity loss. We prospectively enrolled 100 living kidney donors from seven Canadian centers between 2004 and 2008 and collected and valued economic consequences ($CAD 2008) at 3 months and 1 year after donation. Almost all (96%) donors experienced economic consequences, with 94% reporting travel costs and 47% reporting lost pay. The average and median costs of lost pay were $2144 (SD 4167) and $0 (25th-75th percentile 0, 2794), respectively. For other expenses (travel, accommodation, medication and medical), mean and median costs were $1780 (SD 2504) and $821 (25th-75th percentile 242, 2271), respectively. From the donor perspective, mean cost was $3268 (SD 4704); one-third of donors incurred cost >$3000, and 15% >$8000. The majority of donors (83%) reported inability to perform usual household activities for an average duration of 33 days; 8% reported out-of-pocket costs for assistance with these activities. The economic impact of living kidney donation for some individuals is large. We advocate for programs to reimburse living donors for their legitimate costs.
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Affiliation(s)
- S Klarenbach
- Department of Medicine, Institute of Health EconomicsEdmonton, AB, Canada,
*Corresponding author: Scott Klarenbach,
| | - J S Gill
- Department of Medicine, University of British ColumbiaVancouver, BC, Canada
| | - G Knoll
- Department of Medicine, University of OttawaOttawa, ON, Canada
| | - T Caulfield
- Faculty of Law, School of Population and Public Health, University of AlbertaEdmonton, AB, Canada
| | - N Boudville
- School of Medicine, University of Western AustraliaCrawley, WA, Canada
| | - G V R Prasad
- Department of Medicine, University of TorontoToronto, ON, Canada
| | - M Karpinski
- Department of Medicine, University of ManitobaWinnipeg, MB, Canada
| | - L Storsley
- Department of Medicine, University of ManitobaWinnipeg, MB, Canada
| | - D Treleaven
- Department of Medicine, McMaster UniversityHamilton, ON, Canada
| | - J Arnold
- University of Western OntarioLondon, ON, Canada
| | - M Cuerden
- University of Western OntarioLondon, ON, Canada
| | - P Jacobs
- Department of Medicine, Institute of Health EconomicsEdmonton, AB, Canada
| | - A X Garg
- Department of Medicine and Department of Epidemiology and Biostatistics, University of Western OntarioLondon, ON, Canada,Department of Clinical Epidemiology and Biostatistics, McMaster UniversityHamilton, ON, Canada
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Gill JS, Klarenbach S, Barnieh L, Caulfield T, Knoll G, Levin A, Cole EH. Financial Incentives to Increase Canadian Organ Donation: Quick Fix or Fallacy? Am J Kidney Dis 2014; 63:133-40. [DOI: 10.1053/j.ajkd.2013.08.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 08/05/2013] [Indexed: 11/11/2022]
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29
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The decline in living kidney donation in the United States: random variation or cause for concern? Transplantation 2013; 96:767-73. [PMID: 23759882 DOI: 10.1097/tp.0b013e318298fa61] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The annual number of living kidney donors in the United States peaked at 6647 in 2004. The preceding decade saw a 120% increase in living kidney donation. However, since 2004, living kidney donation has declined in all but 1 year, resulting in a 13% decline in the annual number of living kidney donors from 2004 to 2011. The proportional decline in living kidney donation has been more pronounced among men, blacks, younger adults, siblings, and parents. In this article, we explore several possible explanations for the decline in living kidney donation, including an increase in medical unsuitability, an aging transplant patient population, financial disincentives, public policies, and shifting practice patterns, among others. We conclude that the decline in living donation is not merely reflective of random variation but one that warrants action by the transplant centers, the broader transplant community, and the state and national governments.
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Dew MA, Myaskovsky L, Steel JL, DiMartini AF. Managing the Psychosocial and Financial Consequences of Living Donation. CURRENT TRANSPLANTATION REPORTS 2013; 1:24-34. [PMID: 24592353 DOI: 10.1007/s40472-013-0003-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
There has been dramatic growth in the last decade in the literature on psychosocial and financial impacts of living organ donation. With this growth has come recognition that these impacts must be considered when educating prospective donors about the donation process, and when planning donor follow-up care after donation. Our review highlights recent studies that provide new information on the nature of psychosocial and financial outcomes in living donors, with special attention to studies examining unrelated donors (i.e., those with no biologic or longstanding emotional connection to the transplant patient), given that these individuals represent a growing segment of the living donor population. Limitations and gaps in available evidence are noted. We also discuss recent recommendations for post-donation monitoring of donors' psychosocial and financial outcomes, and we consider advances in evidence regarding interventions and prevention strategies to minimize any adverse psychosocial and financial impacts of living donation.
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Affiliation(s)
- Mary Amanda Dew
- Departments of Psychiatry, Psychology, Epidemiology, Biostatistics, and Clinical and Translational Science, University of Pittsburgh School of Medicine and Medical Center, 3811 O'Hara Street, Pittsburgh, PA 15213 USA, 412-624-3373
| | - Larissa Myaskovsky
- Departments of Medicine, Psychiatry and Clinical and Translational Science, University of Pittsburgh School of Medicine and Medical Center and Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, 230 McKee Place, Suite 600, Pittsburgh, PA 15213, 412-692-4856
| | - Jennifer L Steel
- Departments of Surgery, Psychiatry and Psychology, University of Pittsburgh School of Medicine and Medical Center, 3459 Fifth Avenue; MUH 7S, Pittsburgh PA 15213, 412-692-2041
| | - Andrea F DiMartini
- Departments of Psychiatry and Surgery, University of Pittsburgh School of Medicine and Medical Center, 3811 O'Hara Street, Pittsburgh, PA 15213 USA, 412-383-3166
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Barnieh L, Gill JS, Klarenbach S, Manns BJ. The cost-effectiveness of using payment to increase living donor kidneys for transplantation. Clin J Am Soc Nephrol 2013; 8:2165-73. [PMID: 24158797 DOI: 10.2215/cjn.03350313] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND OBJECTIVES For eligible candidates, transplantation is considered the optimal treatment compared with dialysis for patients with ESRD. The growing number of patients with ESRD requires new strategies to increase the pool of potential donors. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using decision analysis modeling, this study compared a strategy of paying living kidney donors to waitlisted recipients on dialysis with the current organ donation system. In the base case estimate, this study assumed that the number of donors would increase by 5% with a payment of $10,000. Quality of life estimates, resource use, and costs (2010 Canadian dollars) were based on the best available published data. RESULTS Compared with the current organ donation system, a strategy of increasing the number of kidneys for transplantation by 5% by paying living donors $10,000 has an incremental cost-savings of $340 and a gain of 0.11 quality-adjusted life years. Increasing the number of kidneys for transplantation by 10% and 20% would translate into incremental cost-savings of $1640 and $4030 and incremental quality-adjusted life years gain of 0.21 and 0.39, respectively. CONCLUSION Although the impact is uncertain, this model suggests that a strategy of paying living donors to increase the number of kidneys available for transplantation could be cost-effective, even with a transplant rate increase of only 5%. Future work needs to examine the feasibility, legal policy, ethics, and public perception of a strategy to pay living donors.
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Affiliation(s)
- Lianne Barnieh
- Departments of Medicine and, ‖Community Health Sciences, University of Calgary, Calgary, Alberta, Canada;, †Department of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada;, ‡Department of Medicine, University of Alberta, Edmonton, Alberta, Canada, §Alberta Kidney Disease Network, Calgary, Alberta, Canada
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Gill J, Dong J, Rose C, Johnston O, Landsberg D, Gill J. The effect of race and income on living kidney donation in the United States. J Am Soc Nephrol 2013; 24:1872-9. [PMID: 23990679 DOI: 10.1681/asn.2013010049] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Studies of racial disparities in access to living donor kidney transplantation focus mainly on patient factors, whereas donor factors remain largely unexamined. Here, data from the US Census Bureau were combined with data on all African-American and white living kidney donors in the United States who were registered in the United Network for Organ Sharing (UNOS) between 1998 and 2010 (N=57,896) to examine the associations between living kidney donation (LKD) and donor median household income and race. The relative incidence of LKD was determined in zip code quintiles ranked by median household income after adjustment for age, sex, ESRD rate, and geography. The incidence of LKD was greater in higher-income quintiles in both African-American and white populations. Notably, the total incidence of LKD was higher in the African-American population than in the white population (incidence rate ratio [IRR], 1.20; 95% confidence interval [95% CI], 1.17 to 1.24]), but ratios varied by income. The incidence of LKD was lower in the African-American population than in the white population in the lowest income quintile (IRR, 0.84; 95% CI, 0.78 to 0.90), but higher in the African-American population in the three highest income quintiles, with IRRs of 1.31 (95% CI, 1.22 to 1.41) in Q3, 1.50 (95% CI, 1.39 to 1.62) in Q4, and 1.87 (95% CI, 1.73 to 2.02) in Q5. Thus, these data suggest that racial disparities in access to living donor transplantation are likely due to socioeconomic factors rather than cultural differences in the acceptance of LKD.
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Affiliation(s)
- Jagbir Gill
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
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Gill JS, Gill J, Barnieh L, Dong J, Rose C, Johnston O, Tonelli M, Klarenbach S. Income of living kidney donors and the income difference between living kidney donors and their recipients in the United States. Am J Transplant 2012; 12:3111-8. [PMID: 22882723 DOI: 10.1111/j.1600-6143.2012.04211.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Disincentives for living kidney donation are common but are poorly understood. We studied 54 483 living donor kidney transplants in the United States between 2000 and 2009, limiting to those with valid zip code data to allow determination of median household income by linkage to the 2000 U.S. Census. We then determined the income and income difference of donors and recipients. The median household income in donors and recipients was $46 334 ±$17 350 and $46 439 ±$17 743, respectively. Donation-related expenses consume ≥ 1 month's income in 76% of donors. The mean ± standard deviation income difference between recipients and donors in transplants involving a wealthier recipient was $22 760 ± 14 792 and in 90% of transplants the difference was <$40 000 dollars. The findings suggest that the capacity for donors to absorb the financial consequences of donation, or of recipients to reimburse allowable expenses, is limited. There were few transplants with a large difference in recipient and donor income, suggesting that the scope and value of any payment between donors and recipients is likely to be small. We conclude that most donors and recipients have similar modest incomes, suggesting that the costs of donation are a significant burden in the majority of living donor transplants.
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Affiliation(s)
- J S Gill
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada.
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Ephraim PL, Powe NR, Rabb H, Ameling J, Auguste P, Lewis-Boyer L, Greer RC, Crews DC, Purnell TS, Jaar BG, DePasquale N, Boulware LE. The providing resources to enhance African American patients' readiness to make decisions about kidney disease (PREPARED) study: protocol of a randomized controlled trial. BMC Nephrol 2012; 13:135. [PMID: 23057616 PMCID: PMC3489555 DOI: 10.1186/1471-2369-13-135] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 10/08/2012] [Indexed: 01/28/2023] Open
Abstract
Background Living related kidney transplantation (LRT) is underutilized, particularly among African Americans. The effectiveness of informational and financial interventions to enhance informed decision-making among African Americans with end stage renal disease (ESRD) and improve rates of LRT is unknown. Methods/design We report the protocol of the Providing Resources to Enhance African American Patients’ Readiness to Make Decisions about Kidney Disease (PREPARED) Study, a two-phase study utilizing qualitative and quantitative research methods to design and test the effectiveness of informational (focused on shared decision-making) and financial interventions to overcome barriers to pursuit of LRT among African American patients and their families. Study Phase I involved the evidence-based development of informational materials as well as a financial intervention to enhance African American patients’ and families’ proficiency in shared decision-making regarding LRT. In Study Phase 2, we are currently conducting a randomized controlled trial in which patients with new-onset ESRD receive 1) usual dialysis care by their nephrologists, 2) the informational intervention (educational video and handbook), or 3) the informational intervention in addition to the option of participating in a live kidney donor financial assistance program. The primary outcome of the randomized controlled trial will include patients’ self-reported rates of consideration of LRT (including family discussions of LRT, patient-physician discussions of LRT, and identification of a LRT donor). Discussion Results from the PREPARED study will provide needed evidence on ways to enhance the decision to pursue LRT among African American patients with ESRD. Trial registration ClinicalTrials.gov NCT01439516
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Affiliation(s)
- Patti L Ephraim
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, 2024 E. Monument Street, Suite 2-600, Baltimore, MD 21205, USA
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Barnieh L, Klarenbach S, Gill JS, Caulfield T, Manns B. Attitudes toward strategies to increase organ donation: views of the general public and health professionals. Clin J Am Soc Nephrol 2012; 7:1956-63. [PMID: 23024166 DOI: 10.2215/cjn.04100412] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVE The acceptability of financial incentives for organ donation is contentious. This study sought to determine (1) the acceptability of expense reimbursement or financial incentives by the general public, health professionals involved with organ donation and transplantation, and those with or affected by kidney disease and (2) for the public, whether financial incentives would alter their willingness to consider donation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Web-based survey administered to members of the Canadian public, health professionals, and people with or affected by kidney disease asking questions regarding acceptability of strategies to increase living and deceased kidney donation and willingness to donate a kidney under various financial incentives. RESULTS Responses were collected from 2004 members of the Canadian public October 11-18, 2011; responses from health professionals (n=339) and people with or affected by kidney disease (n=268) were collected during a 4-week period commencing October 11, 2011. Acceptability of one or more financial incentives to increase deceased and living donation was noted in >70% and 40% of all groups, respectively. Support for monetary payment for living donors was 45%, 14%, and 27% for the public, health professionals, and people with or affected by kidney disease, respectively. Overall, reimbursement of funeral expenses for deceased donors and a tax break for living donors were the most acceptable. CONCLUSION The general public views regulated financial incentives for living and deceased donation to be acceptable. Future research needs to examine the impact of financial incentives on rates of deceased and living donors.
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Affiliation(s)
- Lianne Barnieh
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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36
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Abstract
PURPOSE OF REVIEW The organ shortage is the major problem in kidney transplantation today. Despite aggressive organ procurement efforts, the supply of donated kidneys, living and deceased, has not matched the growing demand; as a consequence, more and more qualified candidates are suffering on dialysis and then dying before being transplanted. Herein, we provide justification for a regulated system of compensation for donation. RECENT FINDINGS The main argument in favor of compensation is simple-financial incentives will increase donation, so fewer transplant candidates will suffer and die while waiting. In addition, development of a regulated system of compensation is the most effective means of crippling the core economic support for transplant tourism. Because dialysis is so much more expensive than a transplant, compensated donation could be cost-neutral to the healthcare system. Importantly, opinion polls suggest that the public would support compensation. As uncompensated kidney donation is widely accepted, persuasive arguments against compensation must explain why such a system would be morally distinguishable from uncompensated donation. SUMMARY We suggest that the potential advantages of a regulated system of compensation for donation far outweigh any potential disadvantages. It is time to advocate for a change in the law so that trials can be done.
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Abstract
PURPOSE OF REVIEW To explore the scope and implications of emerging global problem of transplant tourism, a practice in which patients seek transplant services (most commonly kidney allografts) in countries other than their permanent residence. Potential remedies that must be implemented if abuses are to be curbed are also offered. RECENT FINDINGS Although traveling abroad for medical services may not be problematic from a number of perspectives, what makes transplant tourism so troubling is its link with organ trafficking and transplant commercialism. Unlike many illegal markets, however, this one is driven by the need of patients with irreversible kidney failure, who, along with kidney vendors, are the most vulnerable participants in the process in terms of medical and financial outcomes. SUMMARY This review explores the scope and implications of transplant tourism, and offers potential remedies that must be implemented if abuses are to be curbed.
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Danguilan R, De Belen-Uriarte R, Jorge S, Lesaca R, Amarillo M, Ampil R, Ona E. National Survey of Filipinos on Acceptance of Incentivized Organ Donation. Transplant Proc 2012; 44:839-42. [DOI: 10.1016/j.transproceed.2012.01.100] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Gibney EM, Doshi MD, Hartmann EL, Parikh CR, Garg AX. Health insurance status of US living kidney donors. Clin J Am Soc Nephrol 2010; 5:912-6. [PMID: 20413444 DOI: 10.2215/cjn.07121009] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Ensuring follow-up of living kidney donors (LKDs) is essential to long-term preventive care. We sought information on health insurance status of US LKDs, with particular attention to age, gender, and ethnicity. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The United Network for Organ Sharing/Organ Procurement Transplantation Network database was queried for associations among age at donation, race, gender, and health insurance status. We studied all US LKDs between July 2004 and September 2006. RESULTS A total of 10,021 LKDs with known health insurance status were studied, 1765 (18%) of whom lacked health insurance at donation. There were 4852 donors without health insurance information. Younger kidney donors had higher rates of being uninsured (age 18 to 34: 26.2%; age 35 to 49: 15.2%; age 50 to 64: 11.2%; age >65: 3.8%; P < 0.0001), as did men (19.5 versus 16.3% for women; P < 0.0001), and ethnic minorities (white 13.4%, black 21%, Hispanic 35.6%, Asian 26.7%; P < 0.0001). CONCLUSIONS This study confirms that younger patients, ethnic minorities, and men are less likely to have health insurance when donating a kidney, which could negatively affect adherence to long-term follow-up.
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Affiliation(s)
- Eric M Gibney
- Piedmont Transplant Center, Piedmont Hospital, Atlanta, Georgia, USA.
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Patricio Burdiles P, Octavio Rojas G. Algunas reflexiones éticas sobre los trasplantes de órganos sólidos. REVISTA MÉDICA CLÍNICA LAS CONDES 2010. [DOI: 10.1016/s0716-8640(10)70541-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Klarenbach S, Barnieh L, Gill J. Is living kidney donation the answer to the economic problem of end-stage renal disease? Semin Nephrol 2009; 29:533-8. [PMID: 19751899 DOI: 10.1016/j.semnephrol.2009.06.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The escalating number and cost of treating patients with end-stage renal disease is a considerable economic concern for health care systems and societies globally. Compared with dialysis, kidney transplantation leads to improved patient survival and quality of life, as well as cost savings to the health payer. Despite efforts to increase kidney transplantation, the gap between supply and demand continues to grow. In this article we explore the economic consideration of both living and deceased transplantation. Although living kidney donation has several advantages from an economic perspective, efforts to increase both deceased and living donation are required. Strategies to increase kidney donation are underfunded, and even costly strategies are likely to lead to net health care savings. However, demonstration of efficacy of these strategies is required to ensure efficient use of resources.
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Affiliation(s)
- Scott Klarenbach
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Alberta, T6G 2G3 Canada.
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Holtzman S, Adcock L, Dubay DA, Therapondos G, Kashfi A, Greenwood S, Renner EL, Grant DR, Levy GA, Abbey SE. Financial, vocational, and interpersonal impact of living liver donation. Liver Transpl 2009; 15:1435-42. [PMID: 19877218 DOI: 10.1002/lt.21852] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The ability to inform prospective donors of the psychosocial risks of living liver donation is currently limited by the scant empirical literature. The present study was designed to examine donor perceptions of the impact of donation on financial, vocational, and interpersonal life domains and identify demographic and clinical factors related to longer recovery times and greater life interference. A total of 143 donors completed a retrospective questionnaire that included a standardized measure of life interference [Illness Intrusiveness Rating Scale (IIRS)] and additional questions regarding the perceived impact of donation. Donor IIRS scores suggested that donors experience a relatively low level of life interference due to donation [1.60 +/- 0.72, with a possible range of 1 ("not very much" interference) to 7 ("very much" interference)]. However, approximately 1 in 5 donors reported that donating was a significant financial burden. Logistic regression analysis revealed that donors with a psychiatric diagnosis at or prior to donation took longer to return to their self-reported predonation level of functioning (odds ratio = 3.78, P = 0.016). Medical complications were unrelated to self-reported recovery time. Multiple regression analysis revealed 4 independent predictors of greater life interference: less time since donation (b = 0.11, P < 0.001), income lower than CAD$100,000 (b = 0.28, P = 0.038), predonation concerns about the donation process (b = 0.24, P = 0.008), and the perception that the recipient is not caring for the new liver (b = 0.12, P = 0.031). In conclusion, life interference due to living liver donation appears to be relatively low. Donors should be made aware of risk factors for greater life disruptions post-surgery and of the potential financial burden of donation.
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Affiliation(s)
- Susan Holtzman
- Department of Psychology, University of British Columbia, Okanagan, Kelowna, BC, Canada. susan.holtzman.ubc.ca
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Abstract
PURPOSE OF REVIEW The number of organs available for the patients on the transplant waitlist remains at a disproportionate low. All possible methods to curtail this shortage, including providing donors with incentives, have been proposed. This article reviews recent publications addressing the benefits and risks involved in incentivizing living donation. RECENT FINDINGS The debate about the ethics, feasibility, and possible models for compensating organ donors has been prominent in recent literature. As certain countries take lead on this initiative, others are cautiously weighing in on the impact implementations of such policies may have on the society, especially on the underprivileged. SUMMARY The shortage of organs has resulted in proposal of strategies that encroach on certain moral and ethical principles. Providing incentives to donors is one such strategy that is likely to receive a lot of attention in the next few years.
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Hippen B. The kidney allocation score: methodological problems, moral concerns and unintended consequences. Am J Transplant 2009; 9:1507-12. [PMID: 19392985 DOI: 10.1111/j.1600-6143.2009.02594.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The growing disparity between the demand for and supply of kidneys for transplantation has generated interest in alternative systems of allocating kidneys from deceased donors. This personal viewpoint focuses attention on the Kidney Allocation Score (KAS) proposal promulgated by the UNOS/OPTN Kidney Committee. I identify several methodological and moral flaws in the proposed system, concluding that any iteration of the KAS proposal should be met with more skepticism than sanguinity.
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Affiliation(s)
- B Hippen
- Metrolina Nephrology Associates, Charlotte, NC, USA.
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Voo TC, Campbell AV, Castro LDD. The Ethics of Organ Transplantation: Shortages and Strategies. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2009. [DOI: 10.47102/annals-acadmedsg.v38n4p359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
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Incentives for organ donation in the United States: feasible alternative or forthcoming apocalypse? Curr Opin Organ Transplant 2009; 14:140-6. [DOI: 10.1097/mot.0b013e3283295e0d] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Current Canadian initiatives to reimburse live organ donors for their non-medical expenses. Canadian Journal of Public Health 2008. [PMID: 19039887 DOI: 10.1007/bf03405443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Living organ donors frequently incur non-medical expenses for travel, accommodation, prescription drugs, loss of income, and child care in conjunction with organ donation. Despite international precedent and widespread public support, Canada currently lacks a unified strategy to reimburse donors for these expenses. In 2005, we communicated with 78 individuals within the field of Canadian transplantation to identify which initiatives for reimbursement of living donors existed in each province. Saskatchewan was the only province in which public employees were granted paid leave for organ donation. Six provincial governments partially reimbursed travel and accommodation. At the federal level, other expenses could be partially reimbursed through an income tax credit, while the Employment Insurance program and the Canada Pension Plan provided funding for donors who become unemployed or develop long-term disability as a result of donation. Charities helped a limited number of patients in financial need through grants and no-interest loans, but funding was generally limited by contributions received. While reimbursing living donors for their non-medical expenses is considered just, existing programs only partially reimburse expenses and are not available in all provinces. Developing future reimbursement policies will remove a disincentive faced by some potential donors, and may increase rates of transplantation in Canada.
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Boulware LE, Troll MU, Plantinga LC, Powe NR. The association of state and national legislation with living kidney donation rates in the United States: a national study. Am J Transplant 2008; 8:1451-70. [PMID: 18510639 PMCID: PMC2574918 DOI: 10.1111/j.1600-6143.2008.02266.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The effect of state legislation and federal policies supporting living donors on living kidney donation rates in the United States is unknown. We studied living kidney donation rates from 1988 to 2006, and we assessed changes in donation before and after the enactment of state legislation and the launch of federal initiatives supporting donors. During the study, 27 states enacted legislation. Among states enacting legislation, there was no statistically significant difference in the average rate of increase in overall living kidney donations after compared to before state legislation enactment (annual increase in donations per 1 000 000 population [95% confidence interval] 2.39 [1.94-2.84] compared to 1.68 [0.89-2.47] respectively, p > 0.05). Among states not enacting legislation, there was a statistically significantly greater annual increase in overall donation rates from 1997 to 2002 compared to before 1997 when federal initiatives commenced, but there was no growth in annual rates after 2002. State and federal legislation were associated with increases in living-unrelated donation. These findings suggest that although existing public policies were not associated with improvements in the majority of donations from living-related donors, they may have had a selective effect on barriers to living-unrelated kidney donation.
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Affiliation(s)
- L. E. Boulware
- Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD, Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD,*Corresponding author: L. Ebony Boulware,
| | - M. U. Troll
- Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD
| | - L. C. Plantinga
- Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD
| | - N. R. Powe
- Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD, Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD
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Abstract
Paymentfor livingkidney donation is illegal in most countries. Arthur Matas believes that legalisation is needed to shorten waiting times, but Jeremy Chapman (doi: 10.1136/bmj.a179) argues that it will reduce the supply of all organs
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Affiliation(s)
- Arthur J Matas
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, Minnesota 55455, USA
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