1
|
Tong J, Shen Y, Xu A, He X, Luo C, Edmondson M, Zhang D, Lu Y, Yan C, Li R, Siegel L, Sun L, Shenkman EA, Morton SC, Malin BA, Bian J, Asch DA, Chen Y. Evaluating site-of-care-related racial disparities in kidney graft failure using a novel federated learning framework. J Am Med Inform Assoc 2024:ocae075. [PMID: 38713006 DOI: 10.1093/jamia/ocae075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 01/09/2024] [Accepted: 03/26/2024] [Indexed: 05/08/2024] Open
Abstract
OBJECTIVES Racial disparities in kidney transplant access and posttransplant outcomes exist between non-Hispanic Black (NHB) and non-Hispanic White (NHW) patients in the United States, with the site of care being a key contributor. Using multi-site data to examine the effect of site of care on racial disparities, the key challenge is the dilemma in sharing patient-level data due to regulations for protecting patients' privacy. MATERIALS AND METHODS We developed a federated learning framework, named dGEM-disparity (decentralized algorithm for Generalized linear mixed Effect Model for disparity quantification). Consisting of 2 modules, dGEM-disparity first provides accurately estimated common effects and calibrated hospital-specific effects by requiring only aggregated data from each center and then adopts a counterfactual modeling approach to assess whether the graft failure rates differ if NHB patients had been admitted at transplant centers in the same distribution as NHW patients were admitted. RESULTS Utilizing United States Renal Data System data from 39 043 adult patients across 73 transplant centers over 10 years, we found that if NHB patients had followed the distribution of NHW patients in admissions, there would be 38 fewer deaths or graft failures per 10 000 NHB patients (95% CI, 35-40) within 1 year of receiving a kidney transplant on average. DISCUSSION The proposed framework facilitates efficient collaborations in clinical research networks. Additionally, the framework, by using counterfactual modeling to calculate the event rate, allows us to investigate contributions to racial disparities that may occur at the level of site of care. CONCLUSIONS Our framework is broadly applicable to other decentralized datasets and disparities research related to differential access to care. Ultimately, our proposed framework will advance equity in human health by identifying and addressing hospital-level racial disparities.
Collapse
Affiliation(s)
- Jiayi Tong
- The Center for Health AI and Synthesis of Evidence (CHASE), Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA 19104, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Yishan Shen
- The Center for Health AI and Synthesis of Evidence (CHASE), Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA 19104, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA 19104, United States
- Applied Mathematics and Computational Science, The University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Alice Xu
- The Center for Health AI and Synthesis of Evidence (CHASE), Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA 19104, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA 19104, United States
- Washington University in St. Louis, St. Louis, MO 63130, United States
| | - Xing He
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL 32611, United States
| | - Chongliang Luo
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, MO 63110, United States
| | | | - Dazheng Zhang
- The Center for Health AI and Synthesis of Evidence (CHASE), Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA 19104, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Yiwen Lu
- The Center for Health AI and Synthesis of Evidence (CHASE), Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA 19104, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Chao Yan
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - Ruowang Li
- Department of Computational Biomedicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Lianne Siegel
- Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota, Minneapolis, MN 55414, United States
| | - Lichao Sun
- Department of Computer Science and Engineering, Lehigh University, Bethlehem, PA 18015, United States
| | - Elizabeth A Shenkman
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL 32611, United States
| | - Sally C Morton
- School of Mathematical and Statistical Sciences, Arizona State University, Tempe, AZ 85287, United States
| | - Bradley A Malin
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
- Department of Computer Science, Vanderbilt University, Nashville, TN 37212, United States
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - Jiang Bian
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL 32611, United States
| | - David A Asch
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
- Leonard Davis Institute of Health Economics, Philadelphia, PA 19104, United States
| | - Yong Chen
- The Center for Health AI and Synthesis of Evidence (CHASE), Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA 19104, United States
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA 19104, United States
- Applied Mathematics and Computational Science, The University of Pennsylvania, Philadelphia, PA 19104, United States
- Leonard Davis Institute of Health Economics, Philadelphia, PA 19104, United States
| |
Collapse
|
2
|
Drewry KM, Buford J, Patzer RE. Access to the Transplant Waiting List: All-too-Familiar Inequities Even Among Younger and Healthier Candidates. Am J Kidney Dis 2024; 83:684-687. [PMID: 38154783 DOI: 10.1053/j.ajkd.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/13/2023] [Accepted: 12/19/2023] [Indexed: 12/30/2023]
Affiliation(s)
- Kelsey M Drewry
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Regenstrief Institute, Center for Health Services Research, Indianapolis, Indiana
| | - Jade Buford
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Rachel E Patzer
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Regenstrief Institute, Center for Health Services Research, Indianapolis, Indiana.
| |
Collapse
|
3
|
Mandelbaum J, Almeda J, Blackwell S, Hopkins JW, Myers K, Hicks S, Daguise VG. An Analysis of the Social Determinants of Health in South Carolina's I-95 Corridor. Health Promot Pract 2024; 25:335-345. [PMID: 36546686 DOI: 10.1177/15248399221142517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND One in four South Carolinians lives in a county along a nearly 200-mile stretch of Interstate 95 (I-95). Stretching from North Carolina to Georgia, this region is among the most rural, economically depressed, and racially/ethnically diverse in the state. Research is needed to identify social factors contributing to adverse health outcomes along the I-95 corridor, guide interventions, and establish a baseline for measuring progress. This study assessed social determinants of health in counties in South Carolina's I-95 corridor relative to the rest of the state. METHOD Data for South Carolina's 46 counties were extracted from the Centers for Disease Control and Prevention Minority Health Social Vulnerability Index (SVI), which grouped 34 census variables into six themes: socioeconomic status, household composition and disability, minority status and language, housing type and transportation, health care infrastructure, and medical vulnerability. Each theme was ranked from 0 (least vulnerable) to 1 (most vulnerable). Measures between regions were compared using the Wilcoxon-Mann-Whitney test. RESULTS Compared with counties outside the I-95 corridor (n = 29), counties in the corridor (n = 17) scored higher on socioeconomic status vulnerability (.67 and .82, respectively) and medical vulnerability (.65 and .79, respectively). No statistically significant differences were found across other themes. CONCLUSION Identifying social determinants of health in South Carolina's I-95 corridor is a crucial first step toward alleviating health disparities in this region. Interventions and policies should be developed in collaboration with local stakeholders to address distal social factors that create and reinforce health disparities.
Collapse
Affiliation(s)
- Jennifer Mandelbaum
- South Carolina Department of Health and Environmental Control, Columbia, SC, USA
- University of South Carolina, Columbia, SC, USA
| | - Jennifer Almeda
- South Carolina Department of Health and Environmental Control, Columbia, SC, USA
| | - Shanikque Blackwell
- South Carolina Department of Health and Environmental Control, Columbia, SC, USA
| | - John W Hopkins
- South Carolina Department of Health and Environmental Control, Columbia, SC, USA
| | - Kristian Myers
- South Carolina Department of Health and Environmental Control, Columbia, SC, USA
| | - Shauna Hicks
- South Carolina Department of Health and Environmental Control, Columbia, SC, USA
| | - Virginie G Daguise
- South Carolina Department of Health and Environmental Control, Columbia, SC, USA
| |
Collapse
|
4
|
Li Y, Menon G, Kim B, Bae S, Quint EE, Clark-Cutaia MN, Wu W, Thompson VL, Crews DC, Purnell TS, Thorpe RJ, Szanton SL, Segev DL, McAdams DeMarco MA. Neighborhood Segregation and Access to Live Donor Kidney Transplantation. JAMA Intern Med 2024; 184:402-413. [PMID: 38372985 PMCID: PMC10877505 DOI: 10.1001/jamainternmed.2023.8184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/10/2023] [Indexed: 02/20/2024]
Abstract
Importance Identifying the mechanisms of structural racism, such as racial and ethnic segregation, is a crucial first step in addressing the persistent disparities in access to live donor kidney transplantation (LDKT). Objective To assess whether segregation at the candidate's residential neighborhood and transplant center neighborhood is associated with access to LDKT. Design, Setting, and Participants In this cohort study spanning January 1995 to December 2021, participants included non-Hispanic Black or White adult candidates for first-time LDKT reported in the US national transplant registry. The median (IQR) follow-up time for each participant was 1.9 (0.6-3.0) years. Main Outcome and Measures Segregation, measured using the Theil H method to calculate segregation tertiles in zip code tabulation areas based on the American Community Survey 5-year estimates, reflects the heterogeneity in neighborhood racial and ethnic composition. To quantify the likelihood of LDKT by neighborhood segregation, cause-specific hazard models were adjusted for individual-level and neighborhood-level factors and included an interaction between segregation tertiles and race. Results Among 162 587 candidates for kidney transplant, the mean (SD) age was 51.6 (13.2) years, 65 141 (40.1%) were female, 80 023 (49.2%) were Black, and 82 564 (50.8%) were White. Among Black candidates, living in a high-segregation neighborhood was associated with 10% (adjusted hazard ratio [AHR], 0.90 [95% CI, 0.84-0.97]) lower access to LDKT relative to residence in low-segregation neighborhoods; no such association was observed among White candidates (P for interaction = .01). Both Black candidates (AHR, 0.94 [95% CI, 0.89-1.00]) and White candidates (AHR, 0.92 [95% CI, 0.88-0.97]) listed at transplant centers in high-segregation neighborhoods had lower access to LDKT relative to their counterparts listed at centers in low-segregation neighborhoods (P for interaction = .64). Within high-segregation transplant center neighborhoods, candidates listed at predominantly minority neighborhoods had 17% lower access to LDKT relative to candidates listed at predominantly White neighborhoods (AHR, 0.83 [95% CI, 0.75-0.92]). Black candidates residing in or listed at transplant centers in predominantly minority neighborhoods had significantly lower likelihood of LDKT relative to White candidates residing in or listed at transplant centers located in predominantly White neighborhoods (65% and 64%, respectively). Conclusions Segregated residential and transplant center neighborhoods likely serve as a mechanism of structural racism, contributing to persistent racial disparities in access to LDKT. To promote equitable access, studies should assess targeted interventions (eg, community outreach clinics) to improve support for potential candidates and donors and ultimately mitigate the effects of segregation.
Collapse
Affiliation(s)
- Yiting Li
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Gayathri Menon
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Byoungjun Kim
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Sunjae Bae
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Evelien E Quint
- Division of Transplant Surgery, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Maya N Clark-Cutaia
- New York University Rory Meyers College of Nursing, New York, New York
- Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Wenbo Wu
- Department of Population Health, New York University Grossman School of Medicine, New York, New York
- Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Valerie L Thompson
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Deidra C Crews
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tanjala S Purnell
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
| | - Roland J Thorpe
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
| | - Sarah L Szanton
- Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Dorry L Segev
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
- Department of Population Health, New York University Grossman School of Medicine, New York, New York
| | - Mara A McAdams DeMarco
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
- Department of Population Health, New York University Grossman School of Medicine, New York, New York
| |
Collapse
|
5
|
Calvelli H, Gardiner H, Gadegbeku C, Reese P, Obradovic Z, Fink E, Gillespie A. A Social Network Analysis of Hemodialysis Clinics: Attitudes Toward Living Donor Kidney Transplant among Influential Patients. Kidney360 2024; 5:577-588. [PMID: 38324254 DOI: 10.34067/kid.0000000000000383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 01/29/2024] [Indexed: 02/08/2024]
Abstract
Key Points
Hemodialysis clinic social networks spread attitudes and behaviors toward kidney transplants.Identifying and characterizing influential patients is a first step in future hemodialysis clinic social network interventions to promote kidney transplantation.
Background
Hemodialysis clinics help develop patient social networks that may spread kidney transplant (KT) attitudes and behaviors. Identifying influential social network members is an important first step to increase KT rates. We mapped the social networks of two hemodialysis facilities to identify which patients were influential using in-degree centrality as a proxy for popularity and influence.
Methods
In this cross-sectional study, we performed a sociocentric social network analysis of patients on hemodialysis in two geographically and demographically different hemodialysis facilities. Statistical and social network analyses were performed using R statistical software.
Results
More patients at facility 1 (N=71) were waitlisted/evaluating living donor KT (50.7% versus 20.0%, P = 0.021), considered KT as very important (70.4% versus 45.0%, P = 0.019), and knew people who received a successful KT (1.0 versus 0.0, P = 0.003). Variables predicting relationship formation at facility 1 were the same shift (β=1.87, 95% confidence interval [CI] [1.19 to 2.55]; P < 0.0001), same sex (β=0.51, 95% CI [0.01 to 1.00]; P = 0.045), younger age (β=−0.03, 95% CI [−0.05 to −0.01]; P = 0.004), different lengths of time on hemodialysis (β=−0.49, 95% CI [−0.86 to −0.12]; P = 0.009), and knowing more people who received a successful KT (β=0.12, 95% CI [0.03 to 0.21]; P = 0.009). Predictive variables at facility 2 (N=40) were the same race (β=2.52, 95% CI [0.39 to 4.65]; P = 0.021) and knowing fewer people with successful KT (β=−0.92, 95% CI [−1.82 to −0.02]; P = 0.045). In-degree centrality was higher at facility 1 (1.1±1.2) compared with facility 2 (0.6±0.9).
Conclusions
Social networks differed between the hemodialysis clinics in structure and prevalent transplant attitudes. Influential patients at facility 1 (measured by in-degree centrality) had positive attitudes toward KT, whereas influential patients at facility 2 had negative attitudes.
Collapse
Affiliation(s)
- Hannah Calvelli
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Heather Gardiner
- Temple University College of Public Health, Philadelphia, Pennsylvania
| | - Crystal Gadegbeku
- Cleveland Clinic Glickman Urological and Kidney Institute, Cleveland, Ohio
| | - Peter Reese
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zoran Obradovic
- Temple University Center for Data Analytics and Biomedical Informatics, Philadelphia, Pennsylvania
| | - Edward Fink
- Temple University School of Media and Communication, Philadelphia, Pennsylvania
| | | |
Collapse
|
6
|
Daw J, Roberts MK, Salim Z, Porter ND, Verdery AM, Ortiz SE. Relationships, race/ethnicity, gender, age, and living kidney donation evaluation willingness. Transpl Immunol 2024; 83:101980. [PMID: 38184217 PMCID: PMC10939764 DOI: 10.1016/j.trim.2023.101980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/18/2023] [Accepted: 12/31/2023] [Indexed: 01/08/2024]
Abstract
Racial/ethnic and gender disparities in living donor kidney transplantation are large and persistent but incompletely explained. One previously unexplored potential contributor to these disparities is differential willingness to donate to recipients in specific relationships such as children, parents, and friends. We collected and analyzed data from an online sample featuring an experimental vignette in which respondents were asked to rate their willingness to donate to a randomly chosen member of their family or social network. Results show very large differences in respondents' willingness to donate to recipients with different relationships to them, favoring children, spouses/partners, siblings, and parents, and disfavoring friends, aunts/uncles, and coworkers. Evidence suggesting an interactive effect between relationship, respondent race/ethnicity, respondent or recipient gender, was limited to a few cases. At the p < 0.05 level, the parent-recipient gender interaction was statistically significant, favoring mothers over fathers, as was other/multiracial respondents' greater willingness to donate to friends compared to Whites. Additionally, other interactions were significant at the p < 0.10 level, such as Hispanics' and women's higher willingness to donate to parents compared to Whites and men respectively, women's lower willingness to donate to friends compared to men, and Blacks' greater willingness to donate to coworkers than Whites. We also examined differences by age and found that older respondents were less willing to donate to recipients other than their parents. Together these results suggest that differential willingness to donate by relationship group may be a moderately important factor in understanding racial/ethnic and gender disparities in living donor kidney transplantation.
Collapse
Affiliation(s)
- Jonathan Daw
- Department of Sociology & Criminology, The Pennsylvania State University.
| | - Mary K Roberts
- Department of Sociology & Criminology, The Pennsylvania State University
| | - Zarmeen Salim
- Department of Sociology & Criminology, The Pennsylvania State University
| | - Nathaniel D Porter
- University Libraries and Department of Sociology, Virginia Polytechnic Institute and State University
| | - Ashton M Verdery
- Department of Sociology & Criminology, The Pennsylvania State University
| | - Selena E Ortiz
- Department of Health Policy and Administration, The Pennsylvania State University
| |
Collapse
|
7
|
Chen Y, Churilla B, Ahn JB, Quint EE, Sandal S, Musunuru A, Pol RA, Hladek MD, Crews DC, Segev DL, McAdams-DeMarco M. Age Disparities in Access to First and Repeat Kidney Transplantation. Transplantation 2024; 108:845-853. [PMID: 37525348 PMCID: PMC10830888 DOI: 10.1097/tp.0000000000004747] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
BACKGROUND Evidence suggests that older patients are less frequently placed on the waiting list for kidney transplantation (KT) than their younger counterparts. The trends and magnitude of this age disparity in access to first KT and repeat KT (re-KT) remain unclear. METHODS Using the US Renal Data System, we identified 2 496 743 adult transplant-naive dialysis patients and 110 338 adult recipients with graft failure between 1995 and 2018. We characterized the secular trends of age disparities and used Cox proportional hazard models to compare the chances of listing and receiving first KT versus re-KT by age (18-64 y versus ≥65 y). RESULTS Older transplant-naive dialysis patients were less likely to be listed (adjusted hazard ratio [aHR] = 0.18; 95% confidence interval [CI], 0.17-0.18) and receive first KT (aHR = 0.88; 95% CI, 0.87-0.89) compared with their younger counterparts. Additionally, older patients with graft failure had a lower chance of being listed (aHR = 0.40; 95% CI, 0.38-0.41) and receiving re-KT (aHR = 0.76; 95% CI, 0.72-0.81). The magnitude of the age disparity in being listed for first KT was greater than that for re-KT ( Pinteraction < 0.001), and there were no differences in the age disparities in receiving first KT or re-KT ( Pinteraction = 0.13). Between 1995 and 2018, the age disparity in listing for first KT reduced significantly ( P < 0.001), but the age disparities in re-KT remained the same ( P = 0.16). CONCLUSIONS Age disparities exist in access to both first KT and re-KT; however, some of this disparity is attenuated among older adults with graft failure. As the proportion of older patients with graft failure rises, a better understanding of factors that preclude their candidacy and identification of appropriate older patients are needed.
Collapse
Affiliation(s)
- Yusi Chen
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, NY
| | - Bryce Churilla
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - JiYoon B. Ahn
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Evelien E. Quint
- Division of Transplant Surgery, Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Shaifali Sandal
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Amrusha Musunuru
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, NY
| | - Robert A. Pol
- Division of Transplant Surgery, Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Deidra C. Crews
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, NY
| | - Mara McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, NY
| |
Collapse
|
8
|
El-Khoury B, Yang TC. Reviewing Racial Disparities in Living Donor Kidney Transplantation: a Socioecological Approach. J Racial Ethn Health Disparities 2024; 11:928-937. [PMID: 36991297 PMCID: PMC10057682 DOI: 10.1007/s40615-023-01573-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/31/2022] [Accepted: 03/19/2023] [Indexed: 03/31/2023]
Abstract
Despite kidney transplantation having superior outcomes to dialytic therapies, disparities continue to exist among rates of kidney transplantation between Black and non-Hispanic White patients, which cannot be explained by differences in individual characteristics. To better evaluate the persistent Black/White disparities in living kidney transplantation, we review the extant literature and include the critical factors and recent development in living kidney transplantation in the socioecological approach. We also emphasize the potential vertical and hierarchical associations among factors in the socioecological model. Specifically, this review explores the possibility that the relatively low living kidney transplantation among Blacks may be a consequence of individual, interpersonal, and structural inequalities in various social and cultural dimensions. At the individual level, the Black/White differences in socioeconomic conditions and transplant knowledge may account for the low transplantation rates among Blacks. Interpersonally, the relatively weak social support and poor communication between Black patients and their providers may contribute to disparities. At the structural level, the race-based glomerular filtration rate (GFR) calculation that is widely used to screen Black donors is a barrier to receiving living kidney transplantation. This factor is directly related to structural racism in the health care system but its potential impact on living donor transplantation is underexplored. Finally, this literature review emphasizes the current perspective that a race-free GFR should be considered and a multidisciplinary and interprofessional perspective is necessary to devise strategies and interventions to reduce the Black/White disparities in living donor kidney transplantation in the U.S.
Collapse
Affiliation(s)
- Bashir El-Khoury
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, USA.
- Civilian Institution Programs, Air Force Institute of Technology, Wright-Patterson Air Force Base, OH, USA.
| | - Tse-Chuan Yang
- Department of Epidemiology, University of Texas Medical Branch, Galveston, USA
- Department of Sociology, University at Albany, State University of New York, Albany, USA
| |
Collapse
|
9
|
Thanabalasingam SJ, Akbari A, Sood MM, Brown PA, White CA, Moorman D, Salman M, Sriperumbuduri S, Hundemer GL. Social determinants of health and dialysis modality selection in patients with advanced chronic kidney disease: A retrospective cohort study. Perit Dial Int 2024:8968608241234525. [PMID: 38445493 DOI: 10.1177/08968608241234525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Social determinants of health are non-medical factors that impact health. For patients with chronic kidney disease (CKD) progressing to kidney failure, the influence of social determinants of health on dialysis modality selection (haemodialysis vs. peritoneal dialysis (PD)) is incompletely understood. METHODS Retrospective cohort study of 981 consecutive patients with advanced CKD referred to the Ottawa Hospital Multi-Care Kidney Clinic (Canada) who progressed to dialysis from 2010 to 2021. Multivariable logistic regression was used to measure odds ratios (OR) for the associations between social determinants of health (education, employment, marital status and residence) and modality of dialysis initiation. RESULTS The mean age and estimated glomerular filtration rate were 64 and 18 mL/min/1.73 m2, respectively. Not having a high school degree was associated with lower odds of initiating dialysis via PD compared to having a college degree (29% vs. 48%, OR 0.55 (95% confidence interval (CI) 0.34-0.88)). Unemployment was associated with lower odds of initiating dialysis via PD compared to active employment (38% vs. 62%, OR 0.40 (95% CI 0.27-0.60)). Being single was associated with lower odds of initiating dialysis via PD compared to being married (35% vs. 48%, adjusted OR 0.52 (95% CI 0.39-0.70)). Living alone at home was associated with lower odds of initiating dialysis via PD compared to living at home with family (33% vs. 47%, adjusted OR 0.55 (95% CI 0.39-0.78)). CONCLUSIONS Social determinants of health including education, employment, marital status and residence are associated with dialysis modality selection. Addressing these 'upstream' social factors may allow for more equitable outcomes during the transition from advanced CKD to kidney failure.
Collapse
Affiliation(s)
| | - Ayub Akbari
- Division of Nephrology, Department of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Manish M Sood
- Division of Nephrology, Department of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Pierre A Brown
- Division of Nephrology, Department of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Christine A White
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Danielle Moorman
- Division of Nephrology, Department of Medicine, University of Ottawa, ON, Canada
| | - Maria Salman
- Division of Nephrology, Department of Medicine, University of Ottawa, ON, Canada
| | - Sriram Sriperumbuduri
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Gregory L Hundemer
- Division of Nephrology, Department of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| |
Collapse
|
10
|
Ford CG, Leyva Y, Kruger ES, Zhu Y, Croswell E, Kendall K, Puttarajapa C, Dew MA, Ng YH, Unruh ML, Myaskovsky L. Predicting Kidney Transplant Evaluation Non-attendance. J Clin Psychol Med Settings 2024; 31:153-162. [PMID: 36959431 PMCID: PMC10035980 DOI: 10.1007/s10880-023-09953-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/25/2023]
Abstract
Non-attendance to kidney transplant evaluation (KTE) appointments is a barrier to optimal care for those with kidney failure. We examined the medical and socio-cultural factors that predict KTE non-attendance to identify opportunities for integrated medical teams to intervene. Patients scheduled for KTE between May, 2015 and June, 2018 completed an interview before their initial KTE appointment. The interview assessed various social determinants of health, including demographic (e.g., income), medical (e.g. co-morbidities), transplant knowledge, cultural (e.g., medical mistrust), and psychosocial (e.g., social support) factors. We used multiple logistic regression analysis to determine the strongest predictor of KTE non-attendance. Our sample (N = 1119) was 37% female, 76% non-Hispanic White, median age 59.4 years (IQR 49.2-67.5). Of note, 142 (13%) never attended an initial KTE clinic appointment. Being on dialysis predicted higher odds of KTE non-attendance (OR 1.76; p = .02; 64% of KTE attendees on dialysis vs. 77% of non-attendees on dialysis). Transplant and nephrology teams should consider working collaboratively with dialysis units to better coordinate care, (e.g., resources to attend appointment or outreach to emphasize the importance of transplant) adjusting the KTE referral and evaluation process to address access issues (e.g., using tele-health) and encouraging partnership with clinical psychologists to promote quality of life for those on dialysis.
Collapse
Affiliation(s)
- C Graham Ford
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Yuridia Leyva
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Eric S Kruger
- Department of Physical Therapy, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Yiliang Zhu
- Department of Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, USA
| | - Emilee Croswell
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, USA
| | | | - Chethan Puttarajapa
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Mary Amanda Dew
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Yue Harn Ng
- Department of Internal Medicine, University of Washington, Seattle, USA
| | - Mark L Unruh
- Department of Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, USA
| | - Larissa Myaskovsky
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Sciences Center, Albuquerque, USA.
- Department of Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, USA.
| |
Collapse
|
11
|
Hoffman AL, Westphal SG, Wekesa D, Miles CD. Impact of OPTN policy 3.7D providing waiting time modification for candidates affected by race-inclusive eGFR calculations: Early results from a single center. Clin Transplant 2024; 38:e15273. [PMID: 38516921 DOI: 10.1111/ctr.15273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/04/2024] [Accepted: 02/12/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION OPTN Policy 3.7D, implemented January 5, 2023, mandates that all kidney transplant programs modify waiting time for candidates affected by race-inclusive eGFR calculations. We report the early impact of this policy change. METHODS Our transplant program reviewed all listed transplant candidates and identified patients potentially eligible for waiting time modification. Eligible candidates received waiting time modification after submission of supporting evidence to the OPTN. We reviewed the impact on waiting time and transplant activity through October 1, 2023. RESULTS Forty-six adult patients on our center's active waiting list self-identified as Black/African American. 25 (54.3%) candidates qualified for waiting time modification. A median 451 (321, 1543.5) additional days of waiting time was added for qualifying patients. Of the 25 patients who qualified for waiting time modification, 11 patients received a deceased donor kidney in the early period following waiting time modification, including 5 patients transplanted within 1 month after modification. CONCLUSIONS Policy 3.7D is one of few national mandates to address specifically structural racism within transplantation. Implementation has yielded near immediate effects with greater than 40% of time-adjusted patients at our center receiving a deceased donor kidney transplant in the initial months after policy enactment. Early assessment demonstrates great potential impact for this policy.
Collapse
Affiliation(s)
- Arika L Hoffman
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Scott G Westphal
- Nebraska Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Debra Wekesa
- Nebraska Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Clifford D Miles
- Nebraska Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| |
Collapse
|
12
|
Wang C, Garg AX, Luo B, Kim SJ, Knoll G, Yohanna S, Treleaven D, McKenzie S, Ip J, Cooper R, Elliott L, Naylor KL. Defining pre-emptive living kidney donor transplantation as a quality indicator. Am J Transplant 2024:S1600-6135(24)00159-X. [PMID: 38395149 DOI: 10.1016/j.ajt.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/31/2024] [Accepted: 02/16/2024] [Indexed: 02/25/2024]
Abstract
Quality indicators in kidney transplants are needed to identify care gaps and improve access to transplants. We used linked administrative health care databases to examine multiple ways of defining pre-emptive living donor kidney transplants, including different patient cohorts and censoring definitions. We included adults from Ontario, Canada with advanced chronic kidney disease between January 1, 2013, to December 31, 2018. We created 4 unique incident patient cohorts, varying the eligibility by the risk of progression to kidney failure and whether individuals had a recorded contraindication to kidney transplant (eg, home oxygen use). We explored the effect of 4 censoring event definitions. Across the 4 cohorts, size varied substantially from 20 663 to 9598 patients, with the largest reduction (a 43% reduction) occurring when we excluded patients with ≥1 recorded contraindication to kidney transplantation. The incidence rate (per 100 person-years) of pre-emptive living donor kidney transplant varied across cohorts from 1.02 (95% CI: 0.91-1.14) for our most inclusive cohort to 2.21 (95% CI: 1.96-2.49) for the most restrictive cohort. Our methods can serve as a framework for developing other quality indicators in kidney transplantation and monitoring and improving access to pre-emptive living donor kidney transplants in health care systems.
Collapse
Affiliation(s)
- Carol Wang
- Division of Nephrology, Western University, London, Ontario, Canada.
| | - Amit X Garg
- Division of Nephrology, Western University, London, Ontario, Canada; ICES, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
| | - Bin Luo
- ICES, Ontario, Canada; Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
| | - S Joseph Kim
- Division of Nephrology and the Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Gregory Knoll
- University of Ottawa, Department of Medicine (Nephrology) and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Seychelle Yohanna
- Division of Nephrology, McMaster University, Hamilton, Ontario, Canada
| | - Darin Treleaven
- Division of Nephrology, McMaster University, Hamilton, Ontario, Canada
| | | | - Jane Ip
- Ontario Renal Network, Ontario Health, Ontario, Canada
| | - Rebecca Cooper
- Ontario Renal Network, Ontario Health, and Trillium Gift of Life Network, Ontario Health, Canada
| | - Lori Elliott
- Ontario Renal Network, Ontario Health, Ontario, Canada
| | - Kyla L Naylor
- ICES, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
| |
Collapse
|
13
|
Harford M, Laster M. Progress made toward equitable transplantation in children and young adults with kidney disease. Pediatr Nephrol 2024:10.1007/s00467-024-06309-5. [PMID: 38347281 DOI: 10.1007/s00467-024-06309-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 05/16/2024]
Abstract
Racial disparities in pediatric kidney transplantation have been well described over the last two decades and include disparities in preemptive transplantation, waitlisting, time from activation to transplantation, living donation, and graft outcomes. Changes to the organ allocation system including the institution of Share 35 in 2005 and the Kidney Allocation System (KAS) of 2014 have resulted in resolution of some, but not all racial-ethnic disparities. Despite overall improvements in time from waitlist activation to transplant, disparities remain in preemptive transplantation, time to waitlisting, and living donor transplantation. Although improving under the KAS, racial disparities remain in graft survival as well. Racial disparity in kidney transplant access and graft survival is an international problem within pediatric nephrology. Although the racial group affected may differ, various minoritized pediatric groups across the world are affected by transplant disparities. Social determinants of health including financial access, language barriers, and the presence of a healthy living donor play a role in mediating these disparities. Further investigation is needed to better understand and intervene upon modifiable social, biological, and cultural factors driving the remaining disparity in transplant outcomes.
Collapse
Affiliation(s)
- Mercedes Harford
- Division of Nephrology, Department of Pediatrics, School of Medicine, Indiana University, 699 Riley Hospital Drive, Rm 230, Indianapolis, IN, 46202, USA
| | - Marciana Laster
- Division of Nephrology, Department of Pediatrics, School of Medicine, Indiana University, 699 Riley Hospital Drive, Rm 230, Indianapolis, IN, 46202, USA.
| |
Collapse
|
14
|
Loor JM, Ford CG, Leyva Y, Swift S, Ng YH, Zhu Y, Dew MA, Peipert JD, Unruh ML, Croswell E, Kendall K, Puttarajappa C, Shapiro R, Myaskovsky L. Do pre-transplant cultural factors predict health-related quality of life after kidney transplantation? Clin Transplant 2024; 38:e15256. [PMID: 38400674 DOI: 10.1111/ctr.15256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 01/16/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Post-transplant health-related quality of life (HRQOL) is associated with health outcomes for kidney transplant (KT) recipients. However, pretransplant predictors of improvements in post-transplant HRQOL remain incompletely understood. Namely, important pretransplant cultural factors, such as experience of discrimination, perceived racism in healthcare, or mistrust of the healthcare system, have not been examined as potential HRQOL predictors. Also, few have examined predictors of decline in HRQOL post-transplant. METHODS Using data from a prospective cohort study, we examined HRQOL change pre- to post-transplant, and novel cultural predictors of the change. We measured physical, mental, and kidney-specific HRQOL as outcomes, and used cultural factors as predictors, controlling for demographic, clinical, psychosocial, and transplant knowledge covariates. RESULTS Among 166 KT recipients (57% male; mean age 50.6 years; 61.4% > high school graduates; 80% non-Hispanic White), we found mental and physical, but not kidney-specific, HRQOL significantly improved post-transplant. No culturally related factors outside of medical mistrust significantly predicted change in any HRQOL outcome. Instead, demographic, knowledge, and clinical factors significantly predicted decline in each HRQOL domain: physical HRQOL-older age, more post-KT complications, higher pre-KT physical HRQOL; mental HRQOL-having less information pre-KT, greater pre-KT mental HRQOL; and, kidney-specific HRQOL-poorer kidney functioning post-KT, lower expectations for physical condition to improve, and higher pre-KT kidney-specific HRQOL. CONCLUSIONS Instead of cultural factors, predictors of HRQOL decline included demographic, knowledge, and clinical factors. These findings are useful for identifying patient groups that may be at greater risk of poorer post-transplant outcomes, in order to target individualized support to patients.
Collapse
Affiliation(s)
- Jamie M Loor
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Sciences, Albuquerque, New Mexico, USA
| | - C Graham Ford
- Durham VA Medical Center, Durham, North Carolina, USA
| | - Yuridia Leyva
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Sciences, Albuquerque, New Mexico, USA
| | - Samuel Swift
- College of Population Health, University of New Mexico, Albuquerque, New Mexico, USA
| | - Yue Harn Ng
- Department of Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Yiliang Zhu
- Department of Internal Medicine, University of New Mexico, School of Medicine, Albuquerque, New Mexico, USA
| | - Mary Amanda Dew
- Department of Psychiatry, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, USA
| | - J Devin Peipert
- Department of Medical Social Sciences and Transplant Outcomes Research Collaboration, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Mark L Unruh
- Department of Internal Medicine, University of New Mexico, School of Medicine, Albuquerque, New Mexico, USA
| | - Emilee Croswell
- Department of Psychiatry, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Chethan Puttarajappa
- Department of Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ron Shapiro
- Mount Sinai Recanati/Miller Transplantation Institute, Icahn School of Medicine, New York, USA
| | - Larissa Myaskovsky
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Sciences, Albuquerque, New Mexico, USA
- Department of Internal Medicine, University of New Mexico, School of Medicine, Albuquerque, New Mexico, USA
| |
Collapse
|
15
|
Pereira CV, Leite ICG, Nogueira MC, Ferreira GF. Spatial analysis of care for patients undergoing dialysis therapy in the state of Minas Gerais, Brazil, between 2015 and 2019. Rev Bras Epidemiol 2024; 27:e240002. [PMID: 38265314 PMCID: PMC10798058 DOI: 10.1590/1980-549720240002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVE To analyze the spatial flow of care for patients undergoing dialysis therapy in the health regions of the State of Minas Gerais. METHODS Ecological study whose population was patients undergoing dialysis therapy in public, philanthropic institutions or whose treatment was paid for by the Unified Health System in private clinics in partnership, in the State of Minas Gerais. Patients were grouped by health region of residence. The proportions of patients who underwent dialysis were calculated, as well as enrollment on the kidney transplant list in their own region of residence or outside it. Person correlations of these proportions with socioeconomic and care indicators of the health regions were estimated. Spatial exploratory techniques estimated general (Moran's I) and local (LISA) spatial correlation coefficients. RESULTS Regions with higher GDP had a higher number of nephrologists and a higher proportion of registrations in the region of residence. A cluster of regions with low GDP was identified further to the northeast of the State (also with lower nephrologist ratio values), a cluster with a high proportion of those registered on the transplant list in the center of the State, and a cluster with a low proportion of dialysis in the same region of residence further southeast. CONCLUSION Regional disparities were evident in relation to the proportion of patients registered on the waiting list for kidney transplantation, the proportion of patients undergoing dialysis in the same region of residence and the proportion of patients registered on the waiting list for kidney transplantation in the same region of residence. residence.
Collapse
Affiliation(s)
| | | | - Mário Círio Nogueira
- Universidade Federal de Juiz de Fora, Department of Public Health – Juiz de Fora (MG), Brazil
| | - Gustavo Fernandes Ferreira
- Hospital Santa Casa de Misericórdia de Juiz de Fora, Department of Nephrology – Juiz de Fora (MG), Brazil
| |
Collapse
|
16
|
Rizzolo K, Shen JI. Barriers to home dialysis and kidney transplantation for socially disadvantaged individuals. Curr Opin Nephrol Hypertens 2024; 33:26-33. [PMID: 38014998 DOI: 10.1097/mnh.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
PURPOSE OF REVIEW People with kidney disease facing social disadvantage have multiple barriers to quality kidney care. The aim of this review is to summarize the patient, clinician, and system wide factors that impact access to quality kidney care and discuss potential solutions to improve outcomes for socially disadvantaged people with kidney disease. RECENT FINDINGS Patient level factors such as poverty, insurance, and employment affect access to care, and low health literacy and kidney disease awareness can affect engagement with care. Clinician level factors include lack of early nephrology referral, limited education of clinicians in home dialysis and transplantation, and poor patient-physician communication. System-level factors such as lack of predialysis care and adequate health insurance can affect timely access to care. Neighborhood level socioeconomic factors, and lack of inclusion of these factors into public policy payment models, can affect ability to access care. Moreover, the effects of structural racism and discrimination nay negatively affect the kidney care experience for racially and ethnically minoritized individuals. SUMMARY Patient, clinician, and system level factors affect access to and engagement in quality kidney care. Multilevel solutions are critical to achieving equitable care for all affected by kidney disease.
Collapse
Affiliation(s)
- Katherine Rizzolo
- Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Section of Nephrology
| | - Jenny I Shen
- The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, USA
| |
Collapse
|
17
|
Shawwa K, Thompson J, Chaudhary V, Parravani A, Poling M, Pellegrino B, Schmidt R. Transplantation, Waitlist Status, and County Indices of Economic Health in West Virginia. Kidney360 2024; 5:73-79. [PMID: 37974322 PMCID: PMC10833601 DOI: 10.34067/kid.0000000000000318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023]
Abstract
Key Points Patients with ESKD coming from impoverished counties are less likely to be waitlisted or transplanted. Insurance status modified the relationship between county poverty rates and waitlisting/transplant. Background Kidney transplantation is the optimal treatment for patients with ESKD. Given lower rates of kidney transplant in West Virginia (WV), we searched for potential predictors, focusing on the indices of economic health. Methods Data on the initiation of RRT, being waitlisted for, and receiving a kidney transplant between 1965 and 2020 were collected from United States Renal Data System. Data on county poverty rate (PR) and economic distress were collected from the Appalachian Regional Commission. Results Of the 23,055 WV patients identified, 2999 (13%) were transplanted compared with 514,050 (15.3%) for the rest of the United States (P < 0.001). Patients who never received a kidney transplant were from counties with higher PRs (17.95%) compared with transplanted patients (17.44%; P < 0.001). Waitlisted patients (2,375) came from counties with lower PRs than those who were never waitlisted (17.48 versus 17.94%; P < 0.001). Waitlisted patients were less likely to be from distressed or at-risk counties (32 versus 34.3%; P = 0.05) than patients who were never waitlisted. In multivariable logistic regression, county PR remained an independent predictor of being transplanted (odds ratio, 0.91; 95% confidence interval, 0.85 to 0.97; P = 0.008) or waitlisted (odds ratio, 0.9; 95% confidence interval, 0.84 to 0.96; P = 0.001) per 5% increase in PR after adjusting for age, sex, body mass index, alcohol use, functional status, and comorbid medical conditions. Group/employer health insurance seemed to modify the relationship between PR and waitlist, where PR remained an independent predictor of waitlisting among patients with insurance. Conclusions Waitlisted patients and transplant recipients from WV were more likely to hail from counties with lower PRs and those in better economic health.
Collapse
Affiliation(s)
- Khaled Shawwa
- Division of Nephrology, Department of Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Jesse Thompson
- Department of Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Vishy Chaudhary
- Division of Nephrology, Department of Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Anthony Parravani
- Division of Nephrology, Department of Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Mark Poling
- Division of Nephrology, Department of Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Bethany Pellegrino
- Division of Nephrology, Department of Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Rebecca Schmidt
- Division of Nephrology, Department of Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
| |
Collapse
|
18
|
Garg N, Thiessen C, Reese PP, Cooper M, Leishman R, Friedewald J, Sharfuddin AA, Nishio Lucar AG, Dadhania DM, Kumar V, Waterman AD, Mandelbrot DA. Temporal trends in kidney paired donation in the United States: 2006-2021 UNOS/OPTN database analysis. Am J Transplant 2024; 24:46-56. [PMID: 37739347 DOI: 10.1016/j.ajt.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/08/2023] [Accepted: 09/11/2023] [Indexed: 09/24/2023]
Abstract
Kidney paired donation (KPD) is a major innovation that is changing the landscape of kidney transplantation in the United States. We used the 2006-2021 United Network for Organ Sharing data to examine trends over time. KPD is increasing, with 1 in 5 living donor kidney transplants (LDKTs) in 2021 facilitated by KPD. The proportion of LDKT performed via KPD was comparable for non-Whites and Whites. An increasing proportion of KPD transplants are going to non-Whites. End-chain recipients are not identified in the database. To what extent these trends reflect how end-chain kidneys are allocated, as opposed to increase in living donation among minorities, remains unclear. Half the LDKT in 2021 in sensitized (panel reactive antibody ≥ 80%) and highly sensitized (panel reactive antibody ≥ 98%) groups occurred via KPD. Yet, the proportion of KPD transplants performed in sensitized recipients has declined since 2013, likely due to changes in the deceased donor allocation policies and newer KPD strategies such as compatible KPD. In 2021, 40% of the programs reported not performing any KPD transplants. Our study highlights the need for understanding barriers to pursuing and expanding KPD at the center level and the need for more detailed and accurate data collection at the national level.
Collapse
Affiliation(s)
- Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.
| | - Carrie Thiessen
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, and Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew Cooper
- Division of Transplantation, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - John Friedewald
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Asif A Sharfuddin
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Angie G Nishio Lucar
- Division of Nephrology, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Darshana M Dadhania
- Division of Nephrology, Department of Medicine, Weill Cornell Medicine-New York Presbyterian Hospital, New York, USA
| | - Vineeta Kumar
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Amy D Waterman
- Houston Methodist Transplant Center and Academic Institute, Houston, Texas, USA
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| |
Collapse
|
19
|
Malas J, Chen Q, Megna D, Zaffiri L, Rampolla RE, Egorova N, Emerson D, Catarino P, Chikwe J, Bowdish ME. Lung transplantation outcomes in patients from socioeconomically distressed communities. J Heart Lung Transplant 2023; 42:1690-1699. [PMID: 37481047 PMCID: PMC10854122 DOI: 10.1016/j.healun.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/15/2023] [Accepted: 07/12/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND Previous studies have demonstrated racial and gender disparities in lung allocation, but contemporary data regarding socioeconomic disparities in post-transplant outcomes are lacking. We evaluated the impact of a composite socioeconomic disadvantage index on post-transplant outcomes. METHODS The Scientific Registry of Transplant Recipients identified 27,763 adult patients undergoing isolated primary lung transplantation between 2005 and 2020. Zip code-level socioeconomic distress was characterized using the Distressed Communities Index (DCI: 0-no distress, 100-severe distress) based on education level, poverty, unemployment, housing vacancies, median income, and business growth, and patients were stratified into high (DCI ≥60) or low (DCI <60) distressed groups. RESULTS Recipients from high-distress communities (n = 8006, 28.8%) were younger (59years [interquartile range {IQR} 50-64] vs 61years [IQR 52-66]), less often white (73 vs 85%), less likely to have a college degree (45 vs 59%), and more likely to have public insurance (57 vs 49%, all p < 0.001) compared to those from low-distress communities. Additionally, high-distress recipients were more likely to have group A diagnoses (32 vs 27%) and undergo bilateral lung transplants (72.4 vs 69.3%, all p < 0.001). Post-transplant survival at 5years was 55.7% (95% confidence interval [CI]: 54.4-56.9) in high-distress recipients and 58.2% (95% CI: 57.4-58.9) in low-distress recipients (p = 0.003). After adjustment, high distress level was independently associated with an increased risk of 5-year mortality (hazard ratio:1.09, 95% CI:1.04-1.15). CONCLUSIONS Recipients from distressed communities are at increased mortality risk following lung transplantation. Efforts should be focused on increased resource allocation and further study to better understand factors which may mitigate this disparity.
Collapse
Affiliation(s)
- Jad Malas
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Qiudong Chen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Dominick Megna
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Lorenzo Zaffiri
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California
| | - Reinaldo E Rampolla
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Cedars Sinai Medical Center, Los Angeles, California
| | - Natalia Egorova
- Department of Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dominic Emerson
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Pedro Catarino
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Michael E Bowdish
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California.
| |
Collapse
|
20
|
Kucirka LM, Angarita AM, Manuck TA, Boggess KA, Derebail VK, Wood ME, Meyer ML, Segev DL, Reynolds ML. Characteristics and Outcomes of Patients With Pregnancy-Related End-Stage Kidney Disease. JAMA Netw Open 2023; 6:e2346314. [PMID: 38064217 PMCID: PMC10709776 DOI: 10.1001/jamanetworkopen.2023.46314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/24/2023] [Indexed: 12/18/2023] Open
Abstract
Importance The incidence of pregnancy-related acute kidney injury is increasing and is associated with significant maternal morbidity including progression to end-stage kidney disease (ESKD). Little is known about characteristics and long-term outcomes of patients who develop pregnancy-related ESKD. Objectives To examine the characteristics and clinical outcomes of patients with pregnancy-related ESKD and to investigate associations between pre-ESKD nephrology care and outcomes. Design, Setting, and Participants This was a cohort study of 183 640 reproductive-aged women with incident ESKD between January 1, 2000, and November 20, 2020, from the US Renal Data System and maternal data from births captured in the US Centers for Disease Control and Prevention publicly available natality data. Data were analyzed from December 2022 to June 2023. Exposure Pregnancy-related primary cause of ESKD, per International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes reported at ESKD onset by the primary nephrologist on Centers for Medicare and Medicaid Services form 2728. Main Outcomes Measures Multivariable Cox proportional hazards and competing risk models were constructed to examine time to (1) mortality, (2) access to kidney transplant (joining the waiting list or receiving a live donor transplant), and (3) receipt of transplant after joining the waitlist. Results A total of 341 patients with a pregnancy-related primary cause of ESKD were identified (mean [SD] age 30.2 [7.3]). Compared with the general US birthing population, Black patients were overrepresented among those with pregnancy-related ESKD (109 patients [31.9%] vs 585 268 patients [16.2%]). In adjusted analyses, patients with pregnancy-related ESKD had similar or lower hazards of mortality compared with those with glomerulonephritis or cystic kidney disease (adjusted hazard ratio [aHR], 0.96; 95% CI, 0.76-1.19), diabetes or hypertension (aHR, 0.49; 95% CI, 0.39-0.61), or other or unknown primary causes of ESKD (aHR, 0.60; 95% CI, 0.48-0.75). Despite this, patients with pregnancy-related ESKD had significantly lower access to kidney transplant compared with those with other causes of ESKD, including (1) glomerulonephritis or cystic kidney disease (adjusted subhazard ratio [aSHR], 0.51; 95% CI, 0.43-0.66), (2) diabetes or hypertension (aSHR, 0.81; 95% CI, 0.67-0.98), and (3) other or unkown cause (aSHR, 0.82; 95% CI, 0.67-0.99). Those with pregnancy-related ESKD were less likely to have nephrology care or have a graft or arteriovenous fistula placed before ESKD onset (nephrology care: adjusted relative risk [aRR], 0.47; 95% CI, 0.40-0.56; graft or arteriovenous fistula placed: aRR, 0.31; 95% CI, 0.17-0.57). Conclusion and Relevance In this study, those with pregnancy-related ESKD had reduced access to transplant and nephrology care, which could exacerbate existing disparities in a disproportionately Black population. Increased access to care could improve quality of life and health outcomes among these young adults with high potential for long-term survival.
Collapse
Affiliation(s)
- Lauren M. Kucirka
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill
| | - Ana M. Angarita
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Tracy A. Manuck
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill
- Institute for Environmental Health Solutions, Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Kim A. Boggess
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill
| | - Vimal K. Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill
| | - Mollie E. Wood
- Department of Epidemiology, Gillings School of Public Health, University of North Carolina at Chapel Hill
- Center for Pharmacoepidemiology, University of North Carolina at Chapel Hill
| | - Michelle L. Meyer
- Department of Emergency Medicine, University of North Carolina at Chapel Hill
| | - Dorry L. Segev
- Division of Transplant, Department of Surgery, New York University Langone Medical Center, New York
| | - Monica L. Reynolds
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill
| |
Collapse
|
21
|
Patel S, Alfafara C, Kraus MB, Buckner-Petty S, Bonner T, Youssef MR, Poterack KA, Mour G, Mathur AK, Milam AJ. Individual- and Community-Level Socioeconomic Status and Deceased Donor Renal Transplant Outcomes. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01851-8. [PMID: 37962790 DOI: 10.1007/s40615-023-01851-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/21/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND This study examined the relationship between socioeconomic status (SES), race, and ethnicity and clinical outcomes following deceased donor kidney transplant (DDKT) at a high-volume transplant center. METHODS This retrospective cohort study used regression models and survival analyses to examine the relationship between individual- and community-level SES, race, and ethnicity and DDKT outcomes (i.e., delayed graft function, graft failure, mortality) adjusting for potential confounders. RESULTS The analytic sample included 3366 patients; 40.7% (n = 1370) were female, the mean age was 54.7 (SD = 13.3) years, 49.3% were non-Hispanic White, and the median follow-up time was 39.5 months (IQR = 24.2-68.1). Patients living in the most disadvantaged communities (using the US Census data) had a higher likelihood of delayed graft function (adjusted relative risk [RR] = 1.12, p = 0.042) and a higher hazard of mortality (adjusted hazard ratio [HR] = 1.32, p = 0.025) compared to patients living in the least disadvantaged communities. Patients without a high school diploma had a higher risk of delayed graft function compared to patients with an associate degree or more (RR = 1.37, p < 0.001). Patients with public insurance coverage had a higher risk of delayed graft function (RR = 1.24, p < 0.001) and a higher hazard of mortality (HR = 1.37, p < 0.001) and graft failure (HR = 1.71, p < 0.001) compared to patients without public insurance. There were no differences in graft failure or mortality by race and ethnicity. CONCLUSIONS SES was not consistently associated with outcomes following DDKT; however, many of the predictors were associated with delayed graft function. With a large and diverse sample size, these findings further the heterogeneity of the present renal transplant research suggesting the need for further investigation to guide implementation of innovative strategies and interventions.
Collapse
Affiliation(s)
- Shyam Patel
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, 85259, USA
| | - Chelsea Alfafara
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Molly B Kraus
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Skye Buckner-Petty
- Department of Clinical Trials and Biostatistics, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Timethia Bonner
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Mohanad R Youssef
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Karl A Poterack
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Girish Mour
- Division of Nephrology, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Amit K Mathur
- Division of Transplant Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Adam J Milam
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA.
| |
Collapse
|
22
|
Islam S, Zhang D, Ho K, Divers J. Racial Disparities in Hospitalization Rates During Long-Term Follow-Up After Deceased-Donor Kidney Transplantation. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01847-4. [PMID: 37930581 DOI: 10.1007/s40615-023-01847-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/23/2023] [Accepted: 10/24/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To compare hospitalization rates between African American (AA) and European American (EA) deceased-donor (DD) kidney transplant (KT) recipients during over a10-year period. METHOD Data from the Scientific Registry of Transplant Recipients and social determinants of health (SDoH), measured by the Social Deprivation Index, were used. Hospitalization rates were estimated for kidney recipients from AA and EA DDs who had one kidney transplanted into an AA and one into an EA, leading to four donor/recipient pairs (DRPs): AA/AA, AA/EA, EA/AA, and EA/EA. Poisson-Gamma models were fitted to assess post-transplant hospitalizations. RESULT Unadjusted hospitalization rates (95% confidence interval) were higher among all DRP involving AA, 131.1 (122.5, 140.3), 134.8 (126.3, 143.8), and 102.4 (98.9, 106.0) for AA/AA, AA/EA, and EA/AA, respectively, compared to 97.1 (93.7, 100.6) per 1000 post-transplant person-years for EA/EA pairs. Multivariable analysis showed u-shaped relationships across SDoH levels within each DRP, but findings varied depending on recipients' race, i.e., AA recipients in areas with the worst SDoH had higher hospitalization rates. However, EA recipients in areas with the best SDoH had higher hospitalization rates than their counterparts. CONCLUSIONS Relationship between healthcare utilization and SDoH depends on DRP, with higher hospitalization rates among AA recipients living in areas with the worst SDoH and among EA recipients in areas with the best SDoH profiles. SDoH plays an important role in driving disparities in hospitalizations after kidney transplantation.
Collapse
Affiliation(s)
- Shahidul Islam
- Department of Foundations of Medicine, Division of Health Services Research, NYU Grossman Long Island School of Medicine, 101 Mineola Blvd, Mineola, NY, 11501, USA.
- NYU Grossman Long Island School of Medicine, Mineola, NY, USA.
| | - Donglan Zhang
- Department of Foundations of Medicine, Division of Health Services Research, NYU Grossman Long Island School of Medicine, 101 Mineola Blvd, Mineola, NY, 11501, USA
- NYU Grossman Long Island School of Medicine, Mineola, NY, USA
| | - Kimberly Ho
- NYU Grossman Long Island School of Medicine, Mineola, NY, USA
| | - Jasmin Divers
- Department of Foundations of Medicine, Division of Health Services Research, NYU Grossman Long Island School of Medicine, 101 Mineola Blvd, Mineola, NY, 11501, USA
- NYU Grossman Long Island School of Medicine, Mineola, NY, USA
| |
Collapse
|
23
|
Husain SA, Yu ME, King KL, Adler JT, Schold JD, Mohan S. Disparities in Kidney Transplant Waitlisting Among Young Patients Without Medical Comorbidities. JAMA Intern Med 2023; 183:1238-1246. [PMID: 37782509 PMCID: PMC10546295 DOI: 10.1001/jamainternmed.2023.5013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 08/07/2023] [Indexed: 10/03/2023]
Abstract
Importance Disparities in kidney transplant referral and waitlisting contribute to disparities in kidney disease outcomes. Whether these differences are rooted in population differences in comorbidity burden is unclear. Objective To examine whether disparities in kidney transplant waitlisting were present among a young, relatively healthy cohort of patients unlikely to have medical contraindications to kidney transplant. Design, Setting, and Participants This retrospective cohort study used the US Renal Data System Registry to identify patients with end-stage kidney disease who initiated dialysis between January 1, 2005, and December 31, 2019. Patients who were older than 40 years, received a preemptive transplant, were preemptively waitlisted, or had documented medical comorbidities other than hypertension or smoking were excluded, yielding an analytic cohort of 52 902 patients. Data were analyzed between March 1, 2022, and February 1, 2023. Main Outcome(s) and Measure(s) Kidney transplant waitlisting after dialysis initiation. Results Of 52 902 patients (mean [SD] age, 31 [5] years; 31 132 [59%] male; 3547 [7%] Asian/Pacific Islander, 20 782 [39%] Black/African American, and 28 006 [53%] White) included in the analysis, 15 840 (30%) were waitlisted for a kidney transplant within 1 year of dialysis initiation, 11 122 (21%) were waitlisted between 1 and 5 years after dialysis initiation, and 25 940 (49%) were not waitlisted by 5 years. Patients waitlisted within 1 year of dialysis initiation were more likely to be male, to be White, to be employed full time, and to have had predialysis nephrology care. There were large state-level differences in the proportion of patients waitlisted within 1 year (median, 33%; range, 15%-58%). In competing risk regression, female sex (adjusted subhazard ratio [SHR], 0.92; 95% CI, 0.90-0.94), Hispanic ethnicity (SHR, 0.77; 95% CI, 0.75-0.80), and Black race (SHR, 0.66; 95% CI, 0.64-0.68) were all associated with lower waitlisting after dialysis initiation. Unemployment (SHR, 0.47; 95% CI, 0.45-0.48) and part-time employment (SHR, 0.74; 95% CI, 0.70-0.77) were associated with lower waitlisting compared with full-time employment, and more than 1 year of predialysis nephrology care, compared with none, was associated with greater waitlisting (SHR, 1.51; 95% CI, 1.46-1.56). Conclusions and Relevance This retrospective cohort study found that fewer than one-third of patients without major medical comorbidities were waitlisted for a kidney transplant within 1 year of dialysis initiation, with sociodemographic disparities in waitlisting even in this cohort of young, relatively healthy patients unlikely to have a medical contraindication to transplantation. Transplant policy changes are needed to increase transparency and address structural barriers to waitlist access.
Collapse
Affiliation(s)
- S. Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Miko E. Yu
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Kristen L. King
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Joel T. Adler
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin
| | - Jesse D. Schold
- Department of Surgery, University of Colorado–Anschutz Medical Campus, Aurora
- Department of Epidemiology, School of Public Health, University of Colorado–Anschutz Medical Campus, Aurora
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| |
Collapse
|
24
|
Buford J, Retzloff S, Wilk AS, McPherson L, Harding JL, Pastan SO, Patzer RE. Race, Age, and Kidney Transplant Waitlisting Among Patients Receiving Incident Dialysis in the United States. Kidney Med 2023; 5:100706. [PMID: 37753250 PMCID: PMC10518364 DOI: 10.1016/j.xkme.2023.100706] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
Abstract
Rationale & Objective Patients with kidney failure from racial and ethnic minority groups and older patients have reduced access to the transplant waitlist relative to White and younger patients. Although racial disparities in the waitlisting group have declined after the 2014 kidney allocation system change, whether there is intersectionality of race and age in waitlisting access is unknown. Study Design Retrospective cohort study. Setting & Participants 439,455 non-Hispanic White and non-Hispanic Black US adults initiating dialysis between 2015 and 2019 were identified from the United States Renal Data System, and followed through 2020. Exposures Patient race and ethnicity (non-Hispanic White and non-Hispanic Black) and age group (18-29, 30-49, 50-64, and 65-80 years). Outcomes Placement on the United Network for Organ Sharing deceased donor waitlist. Analytical Approach Age- and race-stratified waitlisting rates were compared. Multivariable Cox proportional hazards models, censored for death, examined the association between race and waitlisting, and included interaction term for race and age. Results Over a median follow-up period of 1 year, the proportion of non-Hispanic White and non-Hispanic Black patients waitlisted was 20.7% and 20.5%, respectively. In multivariable models, non-Hispanic Black patients were 14% less likely to be waitlisted (aHR, 0.86, 95% CI, 0.77-0.95). Relative differences between non-Hispanic Black and non-Hispanic White patients were different by age group. Non-Hispanic Black patients were 27%, 12%, and 20% less likely to be waitlisted than non-Hispanic White patients for ages 18-29 years (aHR, 0.73; 95% CI, 0.61-0.86), 50-64 (aHR, 0.88; 95% CI, 0.80-0.98), and 65-80 years (aHR, 0.80; 95% CI, 0.71-0.90), respectively, but differences were attenuated among patients aged 30-49 years (aHR, 0.89; 95% CI, 0.77-1.02). Limitations Race and ethnicity data is physician reported, residual confounding, and analysis is limited to non-Hispanic White and non-Hispanic Black patients. Conclusions Racial disparities in waitlisting exist between non-Hispanic Black and non-Hispanic White individuals and are most pronounced among younger patients with kidney failure. Results suggest that interventions to address inequalities in waitlisting may need to be targeted to younger patients with kidney failure. Plain-Language Summary Research has shown that patients from racial and ethnic minority groups and older patients have reduced access to transplant waitlisting relative to White and younger patients; nevertheless, how age impacts racial disparities in waitlisting is unknown. We compared waitlisting between non-Hispanic Black and non-Hispanic White patients with incident kidney failure, within age strata, using registry data for 439,455 US adults starting dialysis (18-80 years) during 2015-2019. Overall, non-Hispanic Black patients were less likely to be waitlisted and relative differences between the two racial groups differed by age. After adjusting for patient-level factors, the largest disparity in waitlisting was observed among adults aged 18-29 years. These results suggest that interventions should target younger adults to reduce disparities in access to kidney transplant waitlisting.
Collapse
Affiliation(s)
- Jade Buford
- Regenstrief Institute, Indianapolis, Indiana
| | - Samantha Retzloff
- HIV Surveillance Branch (HSB), Division of HIV Prevention (DHP), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adam S. Wilk
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Laura McPherson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Jessica L. Harding
- Department of Epidemiology, Rollins School of Public Health, Emory University, Emory University, Emory University School of Medicine, Atlanta, Georgia
- Division of Transplantation, Department of Surgery, Emory University, Emory University School of Medicine, Atlanta, Georgia
- Health Services Research Center, Emory University School of Medicine, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Stephen O. Pastan
- Department of Medicine, Renal Division, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E. Patzer
- Regenstrief Institute, Indianapolis, Indiana
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| |
Collapse
|
25
|
Grossi AA, Randhawa G, Jansen NE, Paredes-Zapata D. Taking a "Care Pathway/Whole Systems" Approach to Equality Diversity Inclusion (EDI) in Organ Donation and Transplantation in Relation to the Needs of "Ethnic/Racial/Migrant" Minority Communities: A Statement and a Call for Action. Transpl Int 2023; 36:11310. [PMID: 37600748 PMCID: PMC10437067 DOI: 10.3389/ti.2023.11310] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 07/13/2023] [Indexed: 08/22/2023]
Abstract
International evidence shows variation in organ donation and transplantation (ODT) based upon a range of patient characteristics. What is less well understood is the impact of patient "ethnicity/race/immigration background," as these terms are defined and intended differently across countries. We also know that these characteristics do not operate in isolation but intersect with a range of factors. In this paper, we propose a framework that seeks to clarify the definition of the key terms "ethnicity/race/migrant" and to review how these communities are operationalized across European studies about inequities in ODT. Further, patients and the public wish to see Equality Diversity Inclusion (EDI) approaches in their everyday lives, not just in relation to ODT. We propose a 'care pathway/whole-systems' approach to ODT encompassing culturally competent public health interventions for a) the prevention and management of chronic diseases, b) improvements in public engagement for the promotion of the culture of ODT and enhancements in end-of-life care, through to c) enhanced likelihood of successful transplant among migrant/ethnic minority communities. Our framework recognizes that if we truly wish to take an EDI approach to ODT, we need to adopt a more social, human and holistic approach to examining questions around patient ethnicity.
Collapse
Affiliation(s)
- Alessandra Agnese Grossi
- Center for Clinical Ethics, Department of Biotechnologies and Life Sciences, University of Insubria, Varese, Italy
- Department of Human Sciences, Innovation and Territory, University of Insubria, Como, Italy
| | - Gurch Randhawa
- Institute for Health Research, University of Bedfordshire, Luton, United Kingdom
| | | | - David Paredes-Zapata
- Donation and Transplant Coordination Section, Hospital Clínic, Barcelona, Spain
- Surgical Department, University of Barcelona, Barcelona, Spain
- Donation and Transplantation Institute Foundation, Barcelona, Spain
| |
Collapse
|
26
|
Browne T, Tindall J. Expanding Access to Living Donor Kidney Transplants Through Social Networks. Kidney Med 2023; 5:100654. [PMID: 37250502 PMCID: PMC10209734 DOI: 10.1016/j.xkme.2023.100654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Affiliation(s)
- Teri Browne
- Address for Correspondence: Teri Browne, PhD, MSW, College of Social Work, University of South Carolina, 1512 Pendleton St, Columbia, SC 29208.
| | | |
Collapse
|
27
|
Chen RJ, Wang JJ, Williamson DFK, Chen TY, Lipkova J, Lu MY, Sahai S, Mahmood F. Algorithmic fairness in artificial intelligence for medicine and healthcare. Nat Biomed Eng 2023; 7:719-742. [PMID: 37380750 PMCID: PMC10632090 DOI: 10.1038/s41551-023-01056-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 04/13/2023] [Indexed: 06/30/2023]
Abstract
In healthcare, the development and deployment of insufficiently fair systems of artificial intelligence (AI) can undermine the delivery of equitable care. Assessments of AI models stratified across subpopulations have revealed inequalities in how patients are diagnosed, treated and billed. In this Perspective, we outline fairness in machine learning through the lens of healthcare, and discuss how algorithmic biases (in data acquisition, genetic variation and intra-observer labelling variability, in particular) arise in clinical workflows and the resulting healthcare disparities. We also review emerging technology for mitigating biases via disentanglement, federated learning and model explainability, and their role in the development of AI-based software as a medical device.
Collapse
Affiliation(s)
- Richard J Chen
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
- Cancer Program, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA, USA
- Cancer Data Science Program, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Judy J Wang
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Drew F K Williamson
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cancer Program, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Tiffany Y Chen
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cancer Program, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Jana Lipkova
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
- Cancer Program, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Ming Y Lu
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cancer Program, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA, USA
- Cancer Data Science Program, Dana-Farber Cancer Institute, Boston, MA, USA
- Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Sharifa Sahai
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
- Cancer Program, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Systems Biology, Harvard Medical School, Boston, MA, USA
| | - Faisal Mahmood
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Cancer Program, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA, USA.
- Cancer Data Science Program, Dana-Farber Cancer Institute, Boston, MA, USA.
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Harvard Data Science Initiative, Harvard University, Cambridge, MA, USA.
| |
Collapse
|
28
|
Taber DJ, Su Z, Gebregziabher M, Mauldin PD, Morinelli TA, Mahmood AO, Magwood GS, Casey MJ, Scalea JR, Kavarana SM, Baliga PK, Rodrigue JR, DuBay DA. Multilevel Intervention to Improve Racial Equity in Access to Kidney Transplant. J Am Coll Surg 2023; 236:721-727. [PMID: 36728400 DOI: 10.1097/xcs.0000000000000542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND African Americans (AAs) have reduced access to kidney transplant (KTX). Our center undertook a multilevel quality improvement endeavor to address KTX access barriers, focused on vulnerable populations. This program included dialysis center patient/staff education, embedding telehealth services across South Carolina, partnering with community providers to facilitate testing/procedures, and increased use of high-risk donors. STUDY DESIGN This was a time series analysis from 2017 to 2021 using autoregression to assess trends in equitable access to KTX for AAs. Equity was measured using a modified version of the Kidney Transplant Equity Index (KTEI), defined as the proportion of AAs in South Carolina with end-stage kidney disease (ESKD) vs the proportion of AAs initiating evaluation, completing evaluation, waitlisting, and undergoing KTX. A KTEI of 1.00 is considered complete equity; a KTEI of <1.00 is indicative of disparity. RESULTS From January 2017 to September 2021, 11,487 ESKD patients (64.7% AA) were referred, 6,748 initiated an evaluation (62.8% AA), 4,109 completed evaluation (59.7% AA), 2,762 were waitlisted (60.0% AA), and 1,229 underwent KTX (55.3% AA). The KTEI for KTX demonstrated significant improvements in equity. The KTEI for initiated evaluations was 0.89 in 2017, improving to 1.00 in 2021 (p = 0.0045). Completed evaluation KTEI improved from 0.85 to 0.95 (p = 0.0230), while waitlist addition KTEI improved from 0.83 to 0.96 (p = 0.0072). The KTEI for KTX also improved from 0.76 to 0.91, which did not reach statistical significance (p = 0.0657). CONCLUSIONS A multilevel intervention focused on improving access to vulnerable populations was significantly associated with reduced disparities for AAs.
Collapse
Affiliation(s)
- David J Taber
- From the Medical University of South Carolina, Division of Transplant Surgery (Taber, Morinelli, Mahmood, Scalea, Kavarana, Baliga, DuBay), Charleston, SC
| | - Zemin Su
- Division of General Internal Medicine and Geriatrics (Su, Mauldin), Charleston, SC
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, College of Medicine (Gebregziabher), Charleston, SC
| | - Patrick D Mauldin
- Division of General Internal Medicine and Geriatrics (Su, Mauldin), Charleston, SC
| | - Thomas A Morinelli
- From the Medical University of South Carolina, Division of Transplant Surgery (Taber, Morinelli, Mahmood, Scalea, Kavarana, Baliga, DuBay), Charleston, SC
| | - Ammar O Mahmood
- From the Medical University of South Carolina, Division of Transplant Surgery (Taber, Morinelli, Mahmood, Scalea, Kavarana, Baliga, DuBay), Charleston, SC
| | - Gayenell S Magwood
- the University of South Carolina, College of Nursing, Columbia, SC (Magwood)
| | | | - Joseph R Scalea
- From the Medical University of South Carolina, Division of Transplant Surgery (Taber, Morinelli, Mahmood, Scalea, Kavarana, Baliga, DuBay), Charleston, SC
| | - Sam M Kavarana
- From the Medical University of South Carolina, Division of Transplant Surgery (Taber, Morinelli, Mahmood, Scalea, Kavarana, Baliga, DuBay), Charleston, SC
| | - Prabhakar K Baliga
- From the Medical University of South Carolina, Division of Transplant Surgery (Taber, Morinelli, Mahmood, Scalea, Kavarana, Baliga, DuBay), Charleston, SC
| | - James R Rodrigue
- the Beth Israel Deaconess Medical Center, Department of Surgery, Boston, MA (Rodrigue)
| | - Derek A DuBay
- From the Medical University of South Carolina, Division of Transplant Surgery (Taber, Morinelli, Mahmood, Scalea, Kavarana, Baliga, DuBay), Charleston, SC
| |
Collapse
|
29
|
Saeed F, Ladwig S, Allen RJ, Eneanya ND, Tamura MK, Fiscella KA. Racial Disparities in Health Beliefs and Advance Care Planning Among Patients Receiving Maintenance Dialysis. J Pain Symptom Manage 2023; 65:318-325. [PMID: 36521766 PMCID: PMC10103744 DOI: 10.1016/j.jpainsymman.2022.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/14/2022]
Abstract
CONTEXT Among people receiving maintenance dialysis, little is known about racial disparities in the occurrence of prognostic discussions, beliefs about future health, and completion of advance care planning (ACP) documents. OBJECTIVES We examined whether Black patients receiving maintenance dialysis differ from White patients in prognostic discussions, beliefs about future health, and completion of ACP-related documents. METHODS We surveyed adult patients receiving maintenance dialysis from seven dialysis units in Cleveland, Ohio, and hospitalized patients at a tertiary care hospital in Cleveland. Of the 450 patients who were asked to participate in the study, 423 (94%) agreed. We restricted the current secondary analyses to include only Black (n=285) and White (n=114) patients. The survey assessed patients' knowledge of their kidney disease, attitudes toward chronic kidney disease (CKD) treatment, preferences for end-of-life (EoL) care, the patient-reported occurrence of prognostic discussions, experiences with kidney therapy decision making, sentiments of dialysis regret, beliefs about health over the next 12 months, and advance care planning. We used stepwise logistic regression to determine if race was associated with the occurrence of prognostic discussions, beliefs about future health, and completion of an ACP-related document, while controlling for potential confounders. RESULTS We found no significant difference in the frequency of prognostic discussions between Black (11.9%) versus White patients (7%) (P=0.15). However, Black patients (19%) had lower odds of believing that their health would worsen over the next 12 months (OR 0.22, CI 0.12, 0.44) and reporting completion of any ACP-related document (OR 0.5, CI 0.32, 0.81) compared to White patients CONCLUSION: Racial differences exist in beliefs about future health and completion of ACP-related documents. Systemic efforts to investigate differences in health beliefs and address racial disparities in the completion of ACP-related documents are needed.
Collapse
Affiliation(s)
- Fahad Saeed
- Department of Medicine, Division of Nephrology (F.S.), University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Division of Palliative Care (F.S., S.L.), University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
| | - Susan Ladwig
- Division of Palliative Care (F.S., S.L.), University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Rebecca Jane Allen
- Mount St. Joseph University, School of Behavior and Natural Science (R.J.A.), Cincinnati, Ohio, USA
| | - Nwamaka D Eneanya
- Fresenius Medical Care, Global Medical Office, Philadelphia, Pennsylvania, USA
| | - Manjula Kurella Tamura
- Division of Nephrology (MKT), Stanford University and Geriatric Research and Education Clinical Center Veterans Affairs Palo Alto, Palo Alto, California, USA
| | - Kevin A Fiscella
- Department of Family Medicine and Center for Center for Communication and Disparities Research (K.A.F.), University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| |
Collapse
|
30
|
Vo A, Tao Y, Li Y, Albarrak A. The Association Between Social Determinants of Health and Population Health Outcomes: Ecological Analysis. JMIR Public Health Surveill 2023; 9:e44070. [PMID: 36989028 PMCID: PMC10131773 DOI: 10.2196/44070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/21/2022] [Accepted: 02/23/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND With the increased availability of data, a growing number of studies have been conducted to address the impact of social determinants of health (SDOH) factors on population health outcomes. However, such an impact is either examined at the county level or the state level in the United States. The results of analysis at lower administrative levels would be useful for local policy makers to make informed health policy decisions. OBJECTIVE This study aimed to investigate the ecological association between SDOH factors and population health outcomes at the census tract level and the city level. The findings of this study can be applied to support local policy makers in efforts to improve population health, enhance the quality of care, and reduce health inequity. METHODS This ecological analysis was conducted based on 29,126 census tracts in 499 cities across all 50 states in the United States. These cities were grouped into 5 categories based on their population density and political affiliation. Feature selection was applied to reduce the number of SDOH variables from 148 to 9. A linear mixed-effects model was then applied to account for the fixed effect and random effects of SDOH variables at both the census tract level and the city level. RESULTS The finding reveals that all 9 selected SDOH variables had a statistically significant impact on population health outcomes for ≥2 city groups classified by population density and political affiliation; however, the magnitude of the impact varied among the different groups. The results also show that 4 SDOH risk factors, namely, asthma, kidney disease, smoking, and food stamps, significantly affect population health outcomes in all groups (P<.01 or P<.001). The group differences in health outcomes for the 4 factors were further assessed using a predictive margin analysis. CONCLUSIONS The analysis reveals that population density and political affiliation are effective delineations for separating how the SDOH affects health outcomes. In addition, different SDOH risk factors have varied effects on health outcomes among different city groups but similar effects within city groups. Our study has 2 policy implications. First, cities in different groups should prioritize different resources for SDOH risk mitigation to maximize health outcomes. Second, cities in the same group can share knowledge and enable more effective SDOH-enabled policy transfers for population health.
Collapse
Affiliation(s)
- Ace Vo
- Information Systems and Business Analytics Department, Loyola Marymount University, Los Angeles, CA, United States
| | - Youyou Tao
- Information Systems and Business Analytics Department, Loyola Marymount University, Los Angeles, CA, United States
| | - Yan Li
- Center for Information Systems and Technology, Claremont Graduate University, Claremont, CA, United States
| | - Abdulaziz Albarrak
- Information Systems Department, King Faisal University, Al-Ahsa, Saudi Arabia
| |
Collapse
|
31
|
Daw J, Roberts M, Gillespie A, Verdery AM, Purnell TS. Testing the Differential Access Hypothesis That Black Kidney Transplant Candidates Perceive Social Network Access to Fewer Potential Living Donors Than White Candidates. Prog Transplant 2023; 33:130-140. [PMID: 36942427 PMCID: PMC10150261 DOI: 10.1177/15269248231164174] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
INTRODUCTION Many studies of Black-White disparities in living donor kidney transplantation hypothesize that they were partially due to Black-White differences in candidate social network access to healthy, willing donors. This differential access hypothesis has not been tested using directly measured social network data. RESEARCH QUESTIONS Do black kidney transplant candidates have perceived lower social network access to health and/or willing living donors than white candidates? DESIGN A cross-sectional survey that measured the social network members was collected in 2015. Black-White differences in patient counts of perceived healthy and/or willing potential donors in social networks, and individual network members' probability of being perceived healthy and/or willing, were compared using logistic and negative binomial regression models. RESULTS The survey included 66 kidney transplant candidates reporting on 1474 social network members at a large Southeastern US transplant center in 2015. Black and White patients had similar access to perceived healthy, likely potential donors (86% vs 87% had 1 or more, P = .92; 5.91 vs 4.13 mean counts, P = .20) and perceived healthy, agreed potential donors (56% vs 48%, P = .54; 1.77 vs 1.74, P = .97). Black patients' network members were individually more likely to be perceived healthy and likely potential donors (26% vs 21%, P = .04), and White patients' network members were more likely to have agreed (13% vs 9%, P = .03), but these differences were statistically insignificant in demographically adjusted models. CONCLUSION Black and White transplant candidates perceived access to similar numbers of potential donors in their social networks. This result does not support the differential access hypothesis.
Collapse
Affiliation(s)
- Jonathan Daw
- Department of Sociology and Criminology and Population Research Institute, 8082The Pennsylvania State University, University Park, PA, USA
| | - Mary Roberts
- Department of Sociology and Criminology and Population Research Institute, 8082The Pennsylvania State University, University Park, PA, USA
| | - Avrum Gillespie
- Section of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Ashton M Verdery
- Department of Sociology and Criminology and Population Research Institute, 8082The Pennsylvania State University, University Park, PA, USA
| | - Tanjala S Purnell
- Department of Epidemiology and Surgery, 1466Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
32
|
Ernst Z, Wilson A, Peña A, Love M, Moore T, Vassar M. Factors associated with health inequities in access to kidney transplantation in the USA: A scoping review. Transplant Rev (Orlando) 2023; 37:100751. [PMID: 36958131 DOI: 10.1016/j.trre.2023.100751] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 02/22/2023] [Accepted: 02/25/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND The kidney is the most needed organ for transplantation in the United States. However, demand and scarcity of this organ has caused significant inequities for historically marginalized groups. In this review, we report on the frequency of inequities in all steps of kidney transplantation from 2016 to 2022. Search criteria was based on the National Institute of Health's (NIH) 2022 list of populations who experience health inequities, which includes: race and ethnicity; sex or gender; Lesbian, Gay, Bisexual, Transgender, Queer + (LGBTQ+); underserved rural communities; education level; income; and occupation status. We outline steps for future research aimed at assessing interventions and programs to improve health outcomes. METHODS This scoping review was developed following guidelines from the Joanna Briggs Institute and PRISMA extension for scoping reviews. In July 2022, we searched Medline (via PubMed) and Ovid Embase databases to identify articles addressing inequities in access to kidney transplantation in the United States. Articles had to address at least one of the NIH's 2022 health inequity groups. RESULTS Our sample of 44 studies indicate that Black race, female sex or gender, and low socioeconomic status are negatively associated with referral, evaluation, and waitlisting for kidney transplantation. Furthermore, only two studies from our sample investigated LGBTQ+ identity since the NIH's addition of SGM in 2016 regarding access to transplantation. Lastly, we found no detectable trend in studies for the four most investigated inequity groups between 2016 and 2022. CONCLUSION Investigations in inequities for access to kidney transplantation for the two most studied groups, race/ethnicity and sex or gender, have shown no change in frequencies. Regarding race and ethnicity, continued interventions focused on educating Black patients and staff of dialysis facilities may increase transplant rates. Studies aimed at assessing effectiveness of the Kidney Paired Donation program are highly warranted due to incompatibility problems in female patients. The sparse representation for the LGBTQ+ population may be due to a lack of standardized data collection for sexual orientation. We recommend this community be engaged via surveys and further investigations.
Collapse
Affiliation(s)
- Zachary Ernst
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America.
| | - Andrew Wilson
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America
| | - Andriana Peña
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America
| | - Mitchell Love
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America
| | - Ty Moore
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America
| | - Matt Vassar
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America; Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America.
| |
Collapse
|
33
|
King KL, Yu M, Husain SA, Patzer RE, Sandra V, Reese PP, Schold JD, Mohan S. Contribution of Estimates of Glomerular Filtration to the Extensive Disparities in Preemptive Listing for Kidney Transplant. Kidney Int Rep 2023; 8:442-454. [PMID: 36938099 PMCID: PMC10014377 DOI: 10.1016/j.ekir.2022.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 12/20/2022] [Indexed: 12/31/2022] Open
Abstract
Introduction The use of race coefficients in equations for estimated glomerular filtration rate (eGFR) may have contributed to racial disparities in access to preemptive (without dialysis exposure) kidney transplantation (Ktx). Methods In this retrospective national cohort study of incident kidney transplant candidates in the United States from 2001 to 2019, we describe temporal trends and racial disparities in preemptive listing and the distribution of eGFR at listing, using eGFR as reported and after removing the race coefficient for Black candidates. Results Among 511,686 candidates, preemptive listing increased over time, from 18% in 2001 to 33% in 2019. Non-Black candidates were listed preemptively nearly twice as frequently as Black candidates in 2019 (38% vs. 21% preemptive) and at higher eGFR values (median 15.6 vs. 15.0 ml/min per 1.73 m2). After adjusting for candidate characteristics, including listing eGFR without the race coefficient, preemptive Black candidates still had significantly lower odds of preemptive deceased donor (DD) kidney transplantation compared to non-Black candidates (odds ratio 0.87, 95% confidence interval: 0.78-0.98). Conclusions Over the last 2 decades, Black patients were consistently less likely to be listed preemptively and were listed at lower eGFR values. Adjusting for listing eGFR with the race coefficient computationally removed did not eliminate the racial disparity, suggesting that additional efforts are needed to achieve equity in preemptive transplantation beyond adopting race-free eGFR equations.
Collapse
Affiliation(s)
- Kristen L. King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Miko Yu
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Columbia University Renal Epidemiology Group, New York, New York, USA
| | - S. Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Rachel E. Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
- Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vanessa Sandra
- Columbia University Renal Epidemiology Group, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Peter P. Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jesse D. Schold
- Department of Surgery, University of Colorado–Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Epidemiology, School of Public Health, University of Colorado–Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Columbia University Renal Epidemiology Group, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
- Correspondence: Sumit Mohan, Division of Nephrology, Department of Medicine, Columbia University Medical Center, 622 West 168th Street, Ph4-124, New York, New York 10032, USA.
| |
Collapse
|
34
|
Park C, Schappe T, Peskoe S, Mohottige D, Chan NW, Bhavsar NA, Boulware LE, Pendergast J, Kirk AD, McElroy LM. A comparison of deprivation indices and application to transplant populations. Am J Transplant 2023; 23:377-386. [PMID: 36695687 DOI: 10.1016/j.ajt.2022.11.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 10/25/2022] [Accepted: 11/26/2022] [Indexed: 01/13/2023]
Abstract
The choice of deprivation index can influence conclusions drawn regarding the extent of deprivation within a community and the identification of the most deprived communities in the United States. This study aimed to determine the degree of correlation among deprivation indices commonly used to characterize transplant populations. We used a retrospective cohort consisting of adults listed for liver or kidney transplants between 2008 and 2018 to compare 4 deprivation indices: neighborhood deprivation index, social deprivation index (SDI), area deprivation index, and social vulnerability index. Pairwise correlation between deprivation indices by transplant referral regions was measured using Spearman correlations of population-weighted medians and upper quartiles. In total, 52 individual variables were used among the 4 deprivation indices with 25% overlap. For both organs, the correlation between the population-weighted 75th percentile of the deprivation indices by transplant referral region was highest between SDI and social vulnerability index (liver and kidney, 0.93) and lowest between area deprivation index and SDI (liver, 0.19 and kidney, 0.15). The choice of deprivation index affects the applicability of research findings across studies examining the relationship between social risk and clinical outcomes. Appropriate application of these measures to transplant populations requires careful index selection based on the intended use and included variable relevance.
Collapse
Affiliation(s)
- Christine Park
- Division of Abdominal Transplant, Department of Surgery, Duke University, Durham, NC, USA
| | - Tyler Schappe
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Sarah Peskoe
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Dinushika Mohottige
- Division of Nephrology, Department of Internal Medicine, Duke University, Duke University, Durham, NC, USA
| | - Norine W Chan
- Division of Abdominal Transplant, Department of Surgery, Duke University, Durham, NC, USA
| | - Nrupen A Bhavsar
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA; Division of General Internal Medicine, Department of Medicine, Duke University, Duke University, Durham, NC, USA
| | - L Ebony Boulware
- Division of General Internal Medicine, Department of Medicine, Duke University, Duke University, Durham, NC, USA
| | - Jane Pendergast
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Allan D Kirk
- Division of Abdominal Transplant, Department of Surgery, Duke University, Durham, NC, USA
| | - Lisa M McElroy
- Division of Abdominal Transplant, Department of Surgery, Duke University, Durham, NC, USA; Department of Population Health Sciences, Duke University, Duke University, Durham, NC, USA.
| |
Collapse
|
35
|
Regev-Epstein LC, Frishberg Y, Davidovits M, Landau D, Magen D, Weismann I, Stern-Zimmer M, Beckerman P, Keinan-Boker L, Calderon-Margalit R, Vivante A. Dialysis in Israeli Children between 1990 and 2020: Trends and International Comparisons. Clin J Am Soc Nephrol 2023; 18:363-373. [PMID: 36722361 PMCID: PMC10103217 DOI: 10.2215/cjn.0000000000000063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 12/22/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Childhood kidney failure is a rare condition with worldwide clinical variability. We used a nationwide multicenter analysis to study the pretransplant course of the entire Israeli pediatric kidney failure population over 30 years. METHODS In this nationwide, population-based, historical cohort study, we analyzed medical and demographic data of all children treated with KRT and reported to the Israeli kidney failure registry in 1990-2020. Statistical analysis was performed with incidence rate corrected for age, ethnicity, and calendar year, using the appropriate age-related general population as denominator. RESULTS During the last 30 years, childhood incidence of kidney failure decreased. Average incidence in 2015-2019 was 9.1 cases per million age-related population (pmarp). Arab and Druze children exhibited higher kidney failure incidence rates than Jewish children (18.4 versus 7.0 cases pmarp for minorities versus Jews). The most common kidney failure etiologies among Arab and Jewish children were congenital anomalies of the kidney and urinary tract (approximately 27%), followed by cystic kidney diseases among Arab children (13%) and glomerulonephritis among Jewish children (16%). The most common etiology among Druze children was primary hyperoxaluria type 1 (33%). Israel's national health insurance provides access to primary health care to all citizens. Accordingly, waiting time for deceased-donor transplantation was equal between all ethnicities. Living-donor kidney transplantation rates among minority populations remained low in comparison with Jews over the entire study period. Although all patient groups demonstrated improvement in survival, overall survival rates were mainly etiology dependent. CONCLUSIONS In Israel, Arab and Druze children had a higher incidence of kidney failure, a unique etiological distribution, and a lower rate of living-donor kidney transplantations compared with Jewish children.
Collapse
Affiliation(s)
- Lilach C. Regev-Epstein
- Department of Pediatrics B, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
- Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Yaacov Frishberg
- Division of Pediatric Nephrology, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Miriam Davidovits
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Daniel Landau
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Daniella Magen
- Pediatric Nephrology Institute, Ruth Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Irit Weismann
- Pediatric Nephrology Unit, Galilee Medical Center, Nahariya, Israel
| | - Michal Stern-Zimmer
- Department of Pediatrics B, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
| | - Pazit Beckerman
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Institute of Nephrology and Hypertension, Sheba Medical Center, Tel Hashomer, Israel
| | - Lital Keinan-Boker
- Israel Center for Disease Control, Ramat Gan, Israel
- School of Public Health, University of Haifa, Haifa, Israel
| | | | - Asaf Vivante
- Department of Pediatrics B, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| |
Collapse
|
36
|
Patzer RE, Zhang R, Buford J, McPherson L, Lee YTH, Urbanski M, Li D, Wilk A, Paul S, Plantinga L, Escoffery C, Pastan SO. The ASCENT Intervention to Improve Access and Reduce Racial Inequalities in Kidney Waitlisting: A Randomized, Effectiveness-Implementation Trial. Clin J Am Soc Nephrol 2023; 18:374-382. [PMID: 36764664 PMCID: PMC10103253 DOI: 10.2215/cjn.0000000000000071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 01/02/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND The US kidney allocation system (KAS) changed in 2014, but dialysis facility staff (including nephrologists, social workers, nurse managers, and facility administrators) had low awareness of how this policy change could affect their patients' access to transplant. We assessed the effectiveness of a multicomponent and multilevel educational and outreach intervention targeting US dialysis facilities with low waitlisting, with a goal of increasing waitlisting and reducing Black versus White racial disparities in waitlisting. METHODS The Allocation System Changes for Equity in Kidney Transplantation (ASCENT) study was a cluster-randomized, pragmatic, multilevel, effectiveness-implementation trial including 655 US dialysis facilities with low waitlisting, randomized to receive either the ASCENT intervention (a performance feedback report, a webinar, and staff and patient educational videos) or an educational brochure. Absolute and relative differences in coprimary outcomes (1-year waitlisting and racial differences in waitlisting) were reported among incident and prevalent patients. RESULTS Among 56,332 prevalent patients, 1-year waitlisting decreased for patients in control facilities (2.72%-2.56%) and remained the same for patients in intervention facilities (2.68%-2.75%). However, the proportion of prevalent Black patients waitlisted in the ASCENT interventions increased from baseline to 1 year (2.52%-2.78%), whereas it remained the same for White patients in the ASCENT intervention facilities (2.66%-2.69%). Among incident patients in ASCENT facilities, 1-year waitlisting increased among Black patients (from 0.87% to 1.07%) but declined among White patients (from 1.54% to 1.27%). Significant racial disparities in waitlisting were observed at baseline, with incident Black patients in ASCENT facilities less likely to waitlist compared with White patients (adjusted odds ratio [aOR], 0.56; 95% confidence interval [CI], 0.35 to 0.92), but 1 year after the intervention, this racial disparity was attenuated (aOR, 0.84; 95% CI, 0.49 to 1.42). CONCLUSIONS The ASCENT intervention may have a small effect on extending the reach of the new KAS policy by attenuating racial disparities in waitlisting among a population of US dialysis facilities with low waitlisting. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER National Institutes of Health ( NCT02879812 ). PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_03_08_CJN09760822.mp3.
Collapse
Affiliation(s)
- Rachel E. Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Rebecca Zhang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jade Buford
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Laura McPherson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Yi-Ting Hana Lee
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Megan Urbanski
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Dong Li
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Adam Wilk
- Department of Health Policy and Management, Rollins School of Public Health, Emory University Atlanta, Georgia
| | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Laura Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Cam Escoffery
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Stephen O. Pastan
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| |
Collapse
|
37
|
Walker CS, Gadegbeku CA. Addressing kidney health disparities with new national policy: the time is now. Cardiovasc Diagn Ther 2023; 13:115-121. [PMID: 36864968 PMCID: PMC9971295 DOI: 10.21037/cdt-22-566] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 02/06/2023] [Indexed: 02/15/2023]
Abstract
End-stage kidney disease (ESKD) affects over 780,000 Americans and is associated with excess morbidity and premature death. Kidney disease health disparities are well-recognized, manifesting as ESKD overburden among racial and ethnic minority populations. Specifically, Black and Hispanic individuals have a 3.4-fold and 1.3-fold greater life risk of developing ESKD than their white counterparts. There is compelling evidence that communities of color have less opportunity to benefit from kidney-specific care throughout the course of their disease, from pre-ESKD, to ESKD home therapies and kidney transplantation. These healthcare inequities have the combined devastating impact of worse outcomes and quality of life for patients and families at a significant financial cost on the healthcare system. In the last three years, across two presidential administrations, bold, broad initiatives have been outlined that, together could lead to significant transformation in kidney health. The Advancing American Kidney Health (AAKH) initiative was established as a national framework to revolutionize kidney care but did not address health equity. More recently, the Advancing Racial Equity executive order was announced, outlining initiatives to promote equity for historically underserved communities. Building from these presidential directives, we outline strategies to address the complex issue of kidney health disparities, focusing on patient awareness, care delivery, scientific advancement, and workforce initiatives. An equity-focused framework will guide policy advancements to reduce the kidney disease burden in susceptible populations and positively impact the health and well-being of all Americans.
Collapse
Affiliation(s)
| | - Crystal A. Gadegbeku
- Department of Kidney Medicine, Cleveland Clinic Health System, Cleveland, OH, USA
| |
Collapse
|
38
|
Lombardi CV, Lang JJ, Li MH, Siddique AB, Koizumi N, Ekwenna O. The Impact of the COVID-19 Pandemic on Kidney Transplant Candidate Waitlist Status across Demographic and Geographic Groups: A National Analysis of UNOS STAR Data. Healthcare (Basel) 2023; 11:healthcare11040612. [PMID: 36833146 PMCID: PMC9956325 DOI: 10.3390/healthcare11040612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 02/09/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
The primary goal of this retrospective study is to understand how the COVID-19 pandemic differentially impacted transplant status across race, sex, age, primary insurance, and geographic regions by examining which candidates: (i) remained on the waitlist, (ii) received transplants, or (iii) were removed from the waitlist due to severe sickness or death on a national level. Methods: The trend analysis aggregated by monthly transplant data from 1 December 2019 to 31 May 2021 (18 months) at the transplant center level. Ten variables about every transplant candidate were extracted from UNOS standard transplant analysis and research (STAR) data and analyzed. Characteristics of demographical groups were analyzed bivariately using t-test or Mann-Whitney U test for continuous variables and using Chi-sq/Fishers exact tests for categorical variables. Results: The trend analysis with the study period of 18 months included 31,336 transplants across 327 transplant centers. Patients experienced a longer waiting time when their registration centers in a county where high numbers of COVID-19 deaths were observed (SHR < 0.9999, p < 0.01). White candidates had a more significant transplant rate reduction than minority candidates (-32.19% vs. -20.15%) while minority candidates were found to have a higher waitlist removal rate than White candidates (9.23% vs. 9.45%). Compared to minority patients, White candidates' sub-distribution hazard ratio of the transplant waiting time was reduced by 55% during the pandemic period. Candidates in the Northwest United States had a more significant reduction in the transplant rate and a greater increase in the removal rate during the pandemic period. Conclusions: Based on this study, waitlist status and disposition varied significantly based on patient sociodemographic factors. During the pandemic period, minority patients, those with public insurance, older patients, and those in counties with high numbers of COVID-19 deaths experienced longer wait times. In contrast, older, White, male, Medicare, and high CPRA patients had a statistically significant higher risk of waitlist removal due to severe sickness or death. The results of this study should be considered carefully as we approach a reopening world post-COVID-19, and further studies should be conducted to elucidate the relationship between transplant candidate sociodemographic status and medical outcomes during this era.
Collapse
Affiliation(s)
- Conner V. Lombardi
- Department of Urology and Transplantation, University of Toledo College of Medicine and Life Sciences, Toledo, OH 43614, USA
| | - Jacob J. Lang
- Department of Urology and Transplantation, University of Toledo College of Medicine and Life Sciences, Toledo, OH 43614, USA
| | - Meng-Hao Li
- Schar School of Policy and Government, George Mason University, Fairfax, VA 22030, USA
| | - Abu Bakkar Siddique
- Schar School of Policy and Government, George Mason University, Fairfax, VA 22030, USA
| | - Naoru Koizumi
- Schar School of Policy and Government, George Mason University, Fairfax, VA 22030, USA
| | - Obi Ekwenna
- Department of Urology and Transplantation, University of Toledo College of Medicine and Life Sciences, Toledo, OH 43614, USA
- Correspondence:
| |
Collapse
|
39
|
Rha B, See I, Dunham L, Kutty PK, Moccia L, Apata IW, Ahern J, Jung S, Li R, Nadle J, Petit S, Ray SM, Harrison LH, Bernu C, Lynfield R, Dumyati G, Tracy M, Schaffner W, Ham DC, Magill SS, O’Leary EN, Bell J, Srinivasan A, McDonald LC, Edwards JR, Novosad S. Vital Signs: Health Disparities in Hemodialysis-Associated Staphylococcus aureus Bloodstream Infections - United States, 2017-2020. MMWR Morb Mortal Wkly Rep 2023; 72:153-159. [PMID: 36757874 PMCID: PMC9925139 DOI: 10.15585/mmwr.mm7206e1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Introduction Racial and ethnic minorities are disproportionately affected by end-stage kidney disease (ESKD). ESKD patients on dialysis are at increased risk for Staphylococcus aureus bloodstream infections, but racial, ethnic, and socioeconomic disparities associated with this outcome are not well described. Methods Surveillance data from the 2020 National Healthcare Safety Network (NHSN) and the 2017-2020 Emerging Infections Program (EIP) were used to describe bloodstream infections among patients on hemodialysis (hemodialysis patients) and were linked to population-based data sources (CDC/Agency for Toxic Substances and Disease Registry [ATSDR] Social Vulnerability Index [SVI], United States Renal Data System [USRDS], and U.S. Census Bureau) to examine associations with race, ethnicity, and social determinants of health. Results In 2020, 4,840 dialysis facilities reported 14,822 bloodstream infections to NHSN; 34.2% were attributable to S. aureus. Among seven EIP sites, the S. aureus bloodstream infection rate during 2017-2020 was 100 times higher among hemodialysis patients (4,248 of 100,000 person-years) than among adults not on hemodialysis (42 of 100,000 person-years). Unadjusted S. aureus bloodstream infection rates were highest among non-Hispanic Black or African American (Black) and Hispanic or Latino (Hispanic) hemodialysis patients. Vascular access via central venous catheter was strongly associated with S. aureus bloodstream infections (NHSN: adjusted rate ratio [aRR] = 6.2; 95% CI = 5.7-6.7 versus fistula; EIP: aRR = 4.3; 95% CI = 3.9-4.8 versus fistula or graft). Adjusting for EIP site of residence, sex, and vascular access type, S. aureus bloodstream infection risk in EIP was highest in Hispanic patients (aRR = 1.4; 95% CI = 1.2-1.7 versus non-Hispanic White [White] patients), and patients aged 18-49 years (aRR = 1.7; 95% CI = 1.5-1.9 versus patients aged ≥65 years). Areas with higher poverty levels, crowding, and lower education levels accounted for disproportionately higher proportions of hemodialysis-associated S. aureus bloodstream infections. Conclusions and implications for public health practice Disparities exist in hemodialysis-associated S. aureus infections. Health care providers and public health professionals should prioritize prevention and optimized treatment of ESKD, identify and address barriers to lower-risk vascular access placement, and implement established best practices to prevent bloodstream infections.
Collapse
|
40
|
Trivedi J, Slaughter MS, Moskowitz WB, Ghaleb S, Das BB. Trends in Contemporary Use of Ventricular Assist Devices in Children Awaiting Heart Transplantation and Their Outcomes by Race/Ethnicity. ASAIO J 2023; 69:210-7. [PMID: 35438653 DOI: 10.1097/MAT.0000000000001747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
This retrospective study included children aged ≤18 years who had durable ventricular assist devices (VADs) as a bridge to transplantation from the United Network Organ Sharing (UNOS) database between 2011 and 2020. We evaluated 90 day waitlist mortality and 1 year posttransplant mortality after VAD implantation in children stratified by race/ethnicity: Black, White, and Others. The VAD was used in a higher proportion of Black children listed for heart transplantation (HT) (26%) versus Other (25%) versus White (22%); p < 0.01. Black children had Medicaid health insurance coverage (67%) predominantly at the time of listing for HT. There was no significant overall difference in waitlist survival among the three groups supported with VAD at the time of listing (log-rank p = 0.4). On the other hand, the 90 day waitlist mortality after the VAD implantation at listing and while listed was the lowest among Black (6%) compared with White (13%) and Other (14%) ( p < 0.01). The multivariate regression analysis showed that Other race (hazard ratio [HR], 2.29; p < 0.01), Black race (HR, 2.13; p < 0.01), use of mechanical ventilation (HR, 1.72; p = 0.01), and Medicaid insurance (HR, 1.54; p = 0.04) were independently associated with increased 1 year posttransplant mortality. In conclusion, Black children had more access to durable VAD support than White children. The 90 day waitlist mortality was significantly lower in Black children compared with White and Other after VAD implantation. However, Black and Other racial/ethnic children with VAD at transplant had higher 1 year posttransplant mortality than White children. Future studies to elucidate the reasons for these disparities are needed.
Collapse
|
41
|
Eguchi N, Tantisattamo E, Chung D, Reddy UG, Ferrey A, Dafoe D, Ichii H. Outcomes Among Undocumented Immigrant Kidney Transplant Recipients in California. JAMA Netw Open 2023; 6:e2254660. [PMID: 36780162 PMCID: PMC9926318 DOI: 10.1001/jamanetworkopen.2022.54660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
IMPORTANCE There are over 2 million undocumented immigrants (UI) in California, where currently, all individuals regardless of immigration status have access to kidney transplant. There is a medical perception that UI face a higher risk of transplant failure due to language barriers and lack of access to immunosuppressive medication and health care when compared with US residents (UR). OBJECTIVE To elucidate the kidney transplant outcomes of UI at an academic medical center in California. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted from a single transplant center during an 8-year study period. Patients who received a kidney transplant at the University of California, Irvine, between January 1, 2012, and September 1, 2019, were included in this study. Data were analyzed from October 2020 to August 2021. EXPOSURES The primary exposure of this study was citizenship status. UI were defined as immigrants residing in the US without permission or legal documentation. MAIN OUTCOMES AND MEASURES The primary end point was all-cause graft loss defined as the return to dialysis, need for a second kidney transplant, or death. The secondary end points of this study were all-cause mortality and rejection. All-cause mortality between the 2 groups was compared using multiple Cox proportional hazard regression analysis. Other transplant outcomes, including all-cause graft loss and acute rejection, were examined by competing risks regressions with mortality and mortality plus graft loss serving as competing risks, respectively. RESULTS Of all 446 consecutive kidney transplant recipients, the mean (SD) age was 47 (13) years; 261 patients (59%) were male, and 114 (26%) were UI. During a median (IQR) follow-up time of 3.39 (0.04-8.11) years, 6 UI and 48 UR experienced all-cause graft loss. UR had a 192% (hazard ratio, 2.92; 95% CI, 1.21-6.85; P = .01) and 343% (hazard ratio, 4.34; 95% CI, 1.05-18.69; P = .04) significantly increased unadjusted risk for all-cause graft loss and all-cause mortality, respectively. These results became nonsignificant and were mostly attenuated when adjusted for age and ethnicity. Finally, there was no difference in incidence rate of kidney allograft rejection between the 2 groups (UR, 3.5 per 100 person-years vs UI, 2.4 per 100 person-years; rate ratio, 1.45; 95% CI, 0.90-5.05; P = .08). CONCLUSIONS AND RELEVANCE This single-center cohort study found that kidney transplant outcomes of UI were not inferior to those of UR. Across the US, however, UI have consistently had unequal access to transplantation. These findings suggest that extending kidney transplants to UI is safe and does not portend worse outcomes. As a result, denying transplant according to immigration status not only results in higher costs but also worse end stage kidney disease outcomes for an already underserved population.
Collapse
Affiliation(s)
| | - Ekamol Tantisattamo
- Division of Nephrology and Hypertension, Department of Medicine, University of California, Irvine
| | - Dean Chung
- Department of Surgery, University of California, Irvine
| | - Uttam G. Reddy
- Division of Nephrology and Hypertension, Department of Medicine, University of California, Irvine
| | - Antoney Ferrey
- Division of Nephrology and Hypertension, Department of Medicine, University of California, Irvine
| | - Donald Dafoe
- Department of Surgery, University of California, Irvine
| | | |
Collapse
|
42
|
Morenz A, Perkins J, Dick A, Young B, Ng YH. Reexamining the Impact of Insurance Type on Kidney Transplant Waitlist Status and Posttransplantation Outcomes in the United States After Implementation of the Affordable Care Act. Transplant Direct 2023; 9:e1442. [PMID: 36743233 PMCID: PMC9891441 DOI: 10.1097/txd.0000000000001442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 11/21/2022] [Accepted: 12/15/2022] [Indexed: 01/27/2023] Open
Abstract
Insurance type, a marker of socioeconomic status, has been associated with poor access to kidney transplant (KT) and worse KT outcomes before the implementation of the Affordable Care Act (ACA) and the revised Kidney Allocation System (KAS). In this study, we assessed if insurance type remained a risk marker for worse waitlist and transplant outcomes after ACA and KAS. Methods Using Scientific Registry of Transplant Recipients data, we assessed insurance type of waitlisted candidates pre- (2008-2014) versus post- (2014-2021) KAS/ACA using chi-square tests. Next, we performed a competing risk analysis to study the effect of private versus public (Medicare, Medicaid, or government-sponsored) insurance on waitlist outcomes and a Cox survival analysis to study posttransplant outcomes while controlling for candidate, and recipient and donor variables, respectively. Results The proportion of overall KT candidates insured by Medicaid increased from pre-KAS/ACA to post-KAS/ACA (from 12 667 [7.3%] to 21 768 [8.8%], P < 0.0001). However, KT candidates with public insurance were more likely to have died or become too sick for KT (subdistribution hazard ratio [SHR] = 1.33, confidence interval [CI], 1.30-1.36) or to receive a deceased donor KT (SHR = 1.57, CI, 1.54-1.60) but less likely to receive a living donor KT (SHR = 0.87, CI, 0.85-0.89). Post-KT, KT recipients with public insurance had greater risk of mortality (relative risks = 1.22, CI, 1.15-1.31) and allograft failure (relative risks = 1.10, CI, 1.03-1.29). Conclusions Although the implementation of ACA marginally increased the proportion of waitlisted candidates with Medicaid, publicly insured KT candidates remained at greater risk of being removed from the waitlist, had lower probability of living donor kidney transplantation, and had greater probability of dying post-KT and allograft failure. Concerted efforts to address factors contributing to these inequities in future studies are needed, with the goal of achieving equity in KT for all.
Collapse
Affiliation(s)
- Anna Morenz
- Department of Medicine, University of Washington, Seattle, WA
| | - James Perkins
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), Department of Surgery, University of Washington, Seattle, WA
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, WA
| | - André Dick
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), Department of Surgery, University of Washington, Seattle, WA
- Division of Transplantation, Department of Surgery, Seattle Children’s Hospital, Seattle, WA
| | - Bessie Young
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Yue-Harn Ng
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), Department of Surgery, University of Washington, Seattle, WA
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| |
Collapse
|
43
|
Katz-Greenberg G, Samoylova ML, Shaw BI, Peskoe S, Mohottige D, Boulware LE, Wang V, McElroy LM. Association of the Affordable Care Act on Access to and Outcomes After Kidney or Liver Transplant: A Transplant Registry Study. Transplant Proc 2023; 55:56-65. [PMID: 36623960 PMCID: PMC11025621 DOI: 10.1016/j.transproceed.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/07/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND To evaluate the effect of the Affordable Care Act (ACA) Medicaid expansion on payor mix among patients on the kidney and liver transplant waiting list as well as waiting list and post-transplant outcomes. DESIGN Using the Scientific Registry of Transplant Recipients, we performed a secondary data analysis of all patients on the kidney and liver transplant waiting list from 2007 to 2018. We described changes in payor mix by timing of state Medicaid expansion. We used competing risks models to estimate cause-specific hazard ratios for the effects of insurance and era on death/delisting and transplant. We used a Poisson regression model to estimate the effect of insurance and era on incidence rate ratio of inactivations on the waiting list. We used Cox proportional hazards models to estimate the effect of insurance and era on graft and patient survival. RESULTS A decade after implementation of the ACA, the prevalence of Medicaid beneficiaries listed for transplant increased by 2.5% (from 7.4% to 9.9%) for kidney and by 2.6% (15.3% to 17.9%) for liver. Expansion states had greater increases than nonexpansion states (kidney 3.8% vs 0.6%, liver 5.3% vs -1.8%). Among wait-listed patients, the magnitude of association of Medicaid insurance vs private insurance with transplant decreased over time for kidney candidates (era 1 subdistribution hazard ratio (SHR), 0.62 [95% CI, 0.60-0.64] vs era 3 SHR, 0.77 [95% CI, 0.74-0.70]) but increased for liver candidates (era 1 SHR, 0.85 [95% CI, 0.83-0.90] vs era 3 SHR 0.79 [95% CI, 0.77-0.82]). Medicaid-insured kidney and liver recipients had greater hazards of graft failure; this did not change over time (kidney: HR, 1.23 [95% CI, 1.06-1.44] liver: HR, 1.05 [95% CI, 0.94-1.17]). CONCLUSIONS For the millions of patients with chronic kidney and liver diseases, implementation of the ACA has resulted in only modest increases in access to transplant for the publicly insured vs the privately insured.
Collapse
Affiliation(s)
| | | | - Brian I Shaw
- Department of Surgery, Duke University, Durham, North Carolina
| | - Sarah Peskoe
- Department of Biostatistics, Duke University, Durham, North Carolina
| | | | - L Ebony Boulware
- Department of Medicine, Duke University, Durham, North Carolina; Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Virginia Wang
- Department of Medicine, Duke University, Durham, North Carolina; Department of Population Health Sciences, Duke University, Durham, North Carolina; Center of Innovation for Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Lisa M McElroy
- Department of Surgery, Duke University, Durham, North Carolina; Department of Population Health Sciences, Duke University, Durham, North Carolina
| |
Collapse
|
44
|
Jadlowiec CC, Thongprayoon C, Leeaphorn N, Kaewput W, Pattharanitima P, Cooper M, Cheungpasitporn W. Use of Machine Learning Consensus Clustering to Identify Distinct Subtypes of Kidney Transplant Recipients With DGF and Associated Outcomes. Transpl Int 2022; 35:10810. [PMID: 36568137 PMCID: PMC9773391 DOI: 10.3389/ti.2022.10810] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 11/14/2022] [Indexed: 12/14/2022]
Abstract
Data and transplant community opinion on delayed graft function (DGF), and its impact on outcomes, remains varied. An unsupervised machine learning consensus clustering approach was applied to categorize the clinical phenotypes of kidney transplant (KT) recipients with DGF using OPTN/UNOS data. DGF was observed in 20.9% (n = 17,073) of KT and most kidneys had a KDPI score <85%. Four distinct clusters were identified. Cluster 1 recipients were young, high PRA re-transplants. Cluster 2 recipients were older diabetics and more likely to receive higher KDPI kidneys. Cluster 3 recipients were young, black, and non-diabetic; they received lower KDPI kidneys. Cluster 4 recipients were middle-aged, had diabetes or hypertension and received well-matched standard KDPI kidneys. By cluster, one-year patient survival was 95.7%, 92.5%, 97.2% and 94.3% (p < 0.001); one-year graft survival was 89.7%, 87.1%, 91.6%, and 88.7% (p < 0.001). There were no differences between clusters after accounting for death-censored graft loss (p = 0.08). Clinically meaningful differences in recipient characteristics were noted between clusters, however, after accounting for death and return to dialysis, there were no differences in death-censored graft loss. Greater emphasis on recipient comorbidities as contributors to DGF and outcomes may help improve utilization of DGF at-risk kidneys.
Collapse
Affiliation(s)
- Caroline C. Jadlowiec
- Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, United States,*Correspondence: Caroline C. Jadlowiec,
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, United States
| | - Napat Leeaphorn
- Renal Transplant Program, University of Missouri-Kansas City School of Medicine, Saint Luke’s Health System, Kansas City, MO, United States
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok, Thailand
| | | | - Matthew Cooper
- Medstar Georgetown Transplant Institute, Georgetown University, Washington, DC, United States
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
45
|
Bruschwein H, Chen G, Yost J. Social support and transplantation. Curr Opin Organ Transplant 2022; 27:508-513. [PMID: 36103142 DOI: 10.1097/mot.0000000000001022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Social support has many benefits for patients undergoing organ transplantation, though inclusion of it as criteria for transplant listing has been debated. This review highlights recent developments in the research regarding social support and organ transplantation, including the impact of social support on transplantation and caregivers, interventions, COVID-19, and ethical perspectives. RECENT FINDINGS Social support and perceived social support have benefits for transplant patients, including increased quality of life and adherence. The providers of social support may also be impacted and the impact may vary based on patient and caregiver characteristics, including organ group and caregiver ethnicity. Debates regarding COVID-19 vaccine requirements for caregivers and ethical concerns about the inclusion of social support as criteria for transplant listing are also explored. SUMMARY Transplant patients benefit from social support, though additional research is needed on the impact of social support on transplant outcomes and the utility of the use of social support as criteria for transplant listing. There is also a need for more robust research on diverse caregiver populations, including the identification and use of supportive interventions for caregivers.
Collapse
Affiliation(s)
- Heather Bruschwein
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Gloria Chen
- Abdominal Transplant Center, Dell Seton Medical Center at The University of Texas at Austin, Austin, Texas, USA
| | - Joanna Yost
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville, Virginia
| |
Collapse
|
46
|
Swift SL, Leyva Y, Wang S, Chang CCH, Dew MA, Shapiro R, Unruh M, Kendall K, Croswell E, Peipert JD, Myaskovsky L. Are cultural or psychosocial factors associated with patient-reported outcomes at the conclusion of kidney transplant evaluation? Clin Transplant 2022; 36:e14796. [PMID: 35988025 PMCID: PMC9772103 DOI: 10.1111/ctr.14796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/30/2022] [Accepted: 07/08/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Kidney transplant evaluation (KTE) is a period marked by many stressors for patients, which may lead to poorer patient-reported outcomes (PROs). Research on the association of cultural and psychosocial factors with PROs during KTE is lacking, even though cultural and psychosocial variables may mitigate the relationship between acceptance status and PROs. METHODS Using a prospective cohort study of 955 adults referred for KTE, we examined whether cultural factors and psychosocial characteristics, assessed at the initiation of KTE, are associated with PROs at KTE completion, controlling for demographics and medical factors. Also, we analyzed whether these factors moderate the relationship between transplant acceptance status and PROs. RESULTS In multivariable regression models, a stronger sense of mastery was associated with higher physical and mental QOL. A stronger sense of self-esteem was associated with higher kidney-specific QOL. Depression was associated with a lower mental QOL, but only in those who were accepted for transplant. Having low levels of external locus of control was associated with better mental QOL in those who were not accepted for transplant. Higher anxiety was associated with poorer kidney-specific QOL among those who were not accepted for KT, but trust in physician was only associated with greater satisfaction in transplant clinic service for those who were accepted for KT. CONCLUSIONS Targeting interventions to increase patient mastery and external locus of control, and reduce depression and anxiety in patients undergoing kidney transplant evaluation may be useful approaches to improve their experience during this stressful period.
Collapse
Affiliation(s)
- Samuel L. Swift
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Sciences Center
- SS now at New Mexico Department of Health, Epidemiology
| | - Yuri Leyva
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Sciences Center
| | - Shu Wang
- Department of Biostatistics, University of Florida
| | - Chung-Chou H. Chang
- Department of Biostatistics, University of Pittsburgh, Graduate School of Public Health
- Department of Medicine, University of Pittsburgh, School of Medicine
| | - Mary Amanda Dew
- Department of Psychiatry, University of Pittsburgh, School of Medicine
| | - Ron Shapiro
- Mount Sinai Recanati/Miller Transplantation Institute, Icahn School of Medicine
| | - Mark Unruh
- Department of Internal Medicine, University of New Mexico, School of Medicine
| | | | - Emilee Croswell
- Department of Psychiatry, University of Pittsburgh, School of Medicine
| | - John Devin Peipert
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University
- Northwestern University Transplant Outcomes Research Collaboration (NUTORC), Feinberg School of Medicine, Northwestern University
| | - Larissa Myaskovsky
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Sciences Center
- Department of Internal Medicine, University of New Mexico, School of Medicine
| |
Collapse
|
47
|
Loor JM, Judd NS, Rice CM, Perea DD, Croswell E, Singh PP, Unruh M, Zhu Y, Sehgal AR, Goff SL, Bryce CL, Myaskovsky L. Protocol for the AKT-MP trial: Access to Kidney Transplantation in Minority Populations. Contemp Clin Trials Commun 2022; 30:101015. [PMID: 36246997 PMCID: PMC9562954 DOI: 10.1016/j.conctc.2022.101015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 09/02/2022] [Accepted: 10/01/2022] [Indexed: 11/01/2022] Open
Abstract
Background Kidney transplant (KT) is the optimal treatment for kidney failure (KF), and although completion of KT evaluation is an essential step in gaining access to transplantation, the process is lengthy, time consuming, and burdensome. Furthermore, despite similar referral rates to non-Hispanic Whites, both Hispanic/Latinos and American Indians are less likely to be wait-listed or to undergo KT. Methods The Access to Kidney Transplantation in Minority Populations (AKT-MP) Trial compares two patient-centered methods to facilitate KT evaluation: kidney transplant fast track (KTFT), a streamlined KT evaluation process; and peer navigators (PN), a peer-assisted evaluation program that incorporates motivational interviewing. This pragmatic randomized trial will use a comparative effectiveness approach to assess whether KTFT or PN can help patients overcome barriers to transplant listing. We will randomly assign patients to the two conditions. We will track participants' medical records and conduct surveys prior to their initial evaluation clinic visit and again after they complete or discontinue evaluation. Conclusion Our aims are to (1) compare KTFT and PN to assess improvements in kidney transplant (KT) related outcomes and cost effectiveness; (2) examine how each approach effects changes in cultural/contextual factors, KT concerns, KT knowledge, and KT ambivalence; and (3) develop a framework for widespread implementation of either approach. The results of this trial will provide key information for facilitating the evaluation process, improving patient care, and decreasing disparities in KT.
Collapse
Affiliation(s)
- Jamie M. Loor
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Science Center, United States
| | - Nila S. Judd
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Science Center, United States
| | - Claudia M. Rice
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Science Center, United States
| | - Diana D. Perea
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Science Center, United States
| | - Emilee Croswell
- Department of Psychiatry, University of Pittsburgh, United States
| | - Pooja P. Singh
- Department of Internal Medicine, University of New Mexico, School of Medicine, United States
| | - Mark Unruh
- Department of Internal Medicine, University of New Mexico, School of Medicine, United States
| | - Yiliang Zhu
- Department of Internal Medicine, University of New Mexico, School of Medicine, United States
| | - Ashwini R. Sehgal
- Department of Medicine, Case Western Reserve University, United States
| | - Sarah L. Goff
- Department of Health Policy and Management, University of Massachusetts, Amherst, United States
| | - Cindy L. Bryce
- Department of Health Policy and Management, University of Pittsburgh, School of Public Health, United States
| | - Larissa Myaskovsky
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Science Center, United States,Department of Internal Medicine, University of New Mexico, School of Medicine, United States,Corresponding author. Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Science Center, United States.
| |
Collapse
|
48
|
Abstract
Diagnosis disproportionately affected minority and low-income populations, underscoring the need for broad public health interventions. Fungal infections cause substantial rates of illness and death. Interest in the association between demographic factors and fungal infections is increasing. We analyzed 2019 US hospital discharge data to assess factors associated with fungal infection diagnosis, including race and ethnicity and socioeconomic status. We found male patients were 1.5–3.5 times more likely to have invasive fungal infections diagnosed than were female patients. Compared with hospitalizations of non-Hispanic White patients, Black, Hispanic, and Native American patients had 1.4–5.9 times the rates of cryptococcosis, pneumocystosis, and coccidioidomycosis. Hospitalizations associated with lower-income areas had increased rates of all fungal infections, except aspergillosis. Compared with younger patients, fungal infection diagnosis rates, particularly for candidiasis, were elevated among persons >65 years of age. Our findings suggest that differences in fungal infection diagnostic rates are associated with demographic and socioeconomic factors and highlight an ongoing need for increased physician evaluation of risk for fungal infections.
Collapse
|
49
|
Obayemi J, Keating B, Callans L, Lentine KL, Schnitzler MA, Caliskan Y, Xiao H, Dharnidharka VR, Mannon RB, Axelrod DA. Impact of CYP3A5 Status on the Clinical and Financial Outcomes Among African American Kidney Transplant Recipients. Transplant Direct 2022; 8:e1379. [PMID: 36204191 DOI: 10.1097/TXD.0000000000001379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/06/2022] Open
Abstract
Pharmacogenetic profiling of transplant recipients demonstrates that the marked variation in the metabolism of immunosuppressive medications, particularly tacrolimus, is related to genetic variants. Patients of African ancestry are less likely to carry loss-of-function (LoF) variants in the CYP3A5 gene and therefore retain a rapid metabolism phenotype and higher clearance of tacrolimus. Patients with this rapid metabolism typically require higher dosing to achieve therapeutic trough concentrations. This study aims to further characterize the impact of CYP3A5 genotype on clinical outcomes and financial expenditure.
Collapse
|
50
|
Cooper DL, Manago J, Patel V, Schaar D, Tyno A, Lin Y, Strair R. Universal posttransplant cyclophosphamide after allogeneic transplant, a retrospective single institution study. Leuk Res 2022; 122:106934. [PMID: 36084368 DOI: 10.1016/j.leukres.2022.106934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The excellent results of posttransplant cyclophosphamide in decreasing graft-versus-host disease (GVHD) after haploidentical (HI) allogeneic transplant have challenged current donor selection algorithms. PATIENTS AND METHODS We compared outcomes after matched sibling (MSD) versus alternative donor transplant using identical graft-versus-host disease (GVHD) prophylaxis including posttransplant cyclophosphamide (PTCy. Endpoints included engraftment, time outside of the hospital in the first 100 days after transplant, overall survival (OS), non-relapse mortality (NRM) and percentage of patients disease-free and off immunosuppression (DFOI) at one year and at the last follow-up. RESULTS There were significant differences at baseline between matched donor versus HI donor transplants with higher disease-risk index (DRI), more female-to-male donor recipient pairs and a higher percentage of Black patients in the HI group. Engraftment and time out of the hospital favored MSD and matched unrelated donor transplants. Multivariate analysis showed that high DRI and Black race were associated with decreased survival and Black race was associated with a higher NRM. CONCLUSIONS With the use of PTCy, our results support current donor selection algorithms. The finding of decreased survival and increased NRM in Black patients requires confirmation in a larger number of patients as well as the development of mitigation strategies.
Collapse
Affiliation(s)
| | | | | | | | - Anne Tyno
- Rutgers Cancer Institute of New Jersey, USA
| | - Yong Lin
- Rutgers Cancer Institute of New Jersey, USA
| | | |
Collapse
|