Racial disparities in survival after lung transplantation

Outcomes following lung transplantation for American Indians/Alaska Natives in the United States

Limited data is available for American Indians/Alaska Natives (AI/AN) undergoing lung transplant. The goal of our study was to assess outcomes for AI/AN lung transplant recipients (LTR). A retrospective review of data from the Organ Procurement and Transplant Network was performed comparing AI/AN (n = 88) and Caucasian (n = 22,767) LTRs between May 4, 2005 and October 31, 2019. AI/AN LTRs had worse functional parameters prior to transplantation but had similar post-transplant outcomes compared to Caucasians LTRs.

Racial Disparities in Waiting List Outcomes of Patients Listed for Lung Transplantation

BACKGROUND

The Lung Allocation Score, implemented in 2005, prioritized lung transplant candidates by medical urgency rather than waiting list time and was expected to improve racial disparities in transplant allocation. We evaluated whether racial disparities in lung transplant persisted after 2005.

METHODS

We identified all wait-listed adult lung transplant candidates in the United States from 2005 through 2021 using the Scientific Registry of Transplant Recipients. We evaluated the association between race and receipt of a transplant by using a multivariable competing risk regression model adjusted for demographics, socioeconomic status, Lung Allocation Score, clinical measures, and time. We evaluated interactions between race and age, sex, socioeconomic status, and Lung Allocation Score.

RESULTS

We identified 33,158 candidates on the lung transplant waiting list between 2005 and 2021: 27,074 White (82%), 3350 African American (10%), and 2734 Hispanic (8%). White candidates were older, had higher education levels, and had lower Lung Allocation Scores (P < .001). After multivariable adjustment, African American and Hispanic candidates were less likely to receive lung transplants than White candidates (African American: adjusted subhazard ratio, 0.86; 95% CI, 0.82-0.91; Hispanic: adjusted subhazard ratio, 0.82; 95% CI, 0.78-0.87). Lung transplant was significantly less common among Hispanic candidates aged >65 years (P = .003) and non-White candidates from higher-poverty communities (African-American: P = .013; Hispanic: P =.0036).

CONCLUSIONS

Despite implementation of the Lung Allocation Score, racial disparities persisted for wait-listed African American and Hispanic lung transplant candidates and differed by age and poverty status. Targeted interventions are needed to ensure equitable access to this life-saving intervention.

Does Failure to Rescue Drive Race/Ethnicity-based Disparities in Survival After Heart Transplantation?

OBJECTIVE

The objective was to assess whether race/ethnicity is an independent predictor of failure to rescue (FTR) after orthotopic heart transplantation (OHT).

SUMMARY BACKGROUND DATA

Outcomes following OHT vary by patient level factors; for example, non-White patients have worse outcomes than White patients after OHT. Failure to rescue is an important factor associated with cardiac surgery outcomes, but its relationship to demographic factors is unknown.

METHODS

Using the United Network for Organ Sharing database, we included all adult patients who underwent primary isolated OHT between 1/1/2006 snd 6/30/2021. FTR was defined as the inability to prevent mortality after at least one of the UNOS-designated postoperative complications. Donor, recipient, and transplant characteristics, including complications and FTR, were compared across race/ethnicity. Logistic regression models were created to identify factors associated with complications and FTR. Kaplan Meier and adjusted Cox proportional hazards models evaluated the association between race/ethnicity and posttransplant survival.

RESULTS

There were 33,244 adult, isolated heart transplant recipients included: the distribution of race/ethnicity was 66% (n=21,937) White, 21.2% (7,062) Black, 8.3% (2,768) Hispanic, and 3.3% (1,096) Asian. The frequency of complications and FTR differed significantly by race/ethnicity. After adjustment, Hispanic recipients were more likely to experience FTR than White recipients (OR 1.327, 95% CI[1.075-1.639], P =0.02). Black recipients had lower 5-year survival compared with other races/ethnicities (HR 1.276, 95% CI[1.207-1.348], P <0.0001).

CONCLUSIONS

In the US, Black recipients have an increased risk of mortality after OHT compared with White recipients, without associated differences in FTR. In contrast, Hispanic recipients have an increased likelihood of FTR, but no significant mortality difference compared with White recipients. These findings highlight the need for tailored approaches to addressing race/ethnicity-based health inequities in the practice of heart transplantation.

Historic Use of Race-Based Spirometry Values Lowered Transplant Priority for Black Patients

BACKGROUND

The lung allocation score (LAS) is a tool used to prioritize patients for lung transplantation. For patients with interstitial lung diseases (ILDs), spirometry data are used for the LAS calculation. Spirometry values such as a FVC are subjected to race-specific equations that determine expected values. The effect of race-specific equations in LAS score remains unknown.

RESEARCH QUESTION

Did the use of a race-based spirometry equation lead to longer waitlist times for Black patients?

STUDY DESIGN AND METHODS

We performed a retrospective analysis of patients listed for lung transplantation from 2005 through 2020 using publicly available data from the United Network for Organ Sharing. We recalculated LAS scores for Black patients using White-specific equations with the available variables. The primary objective was to evaluate the effect of race-specific equations on LAS scores and time on the transplant waitlist.

RESULTS

A total of 33,845 patients listed for lung transplantation were included in the analysis. White patients were listed at lower LAS scores, a higher proportion of White patients underwent transplantation, and White patients died on the waitlist at lower rates. When recalculating LAS scores using White-specific equations, Black patients with ILD had up to a 1.9-point higher score, which resulted in additional waitlist time.

INTERPRETATION

Race-specific equations led to longer wait times in Black patients listed for lung transplantation. The use of race-based equations widened already known disparities in pulmonary transplantation.

Lung transplantation outcomes in patients from socioeconomically distressed communities

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.

Extracorporeal membrane oxygenation bridge to pediatric lung transplantation: Modern era analysis

BACKGROUND

Survival outcomes of children on extracorporeal membrane oxygenation (ECMO) at time of lung transplant (LTx) remain unclear.

METHODS

Pediatric first-time LTx recipients transplanted between January 2000 and December 2020 were identified in the United Network for Organ Sharing Registry to compare post-transplant survival according to ECMO support at time of transplant. For a comprehensive analysis of the data, univariate analysis, multivariable Cox regression, and propensity score matching were performed.

RESULTS

During the study period, 954 children under 18 years of age underwent LTx with 40 patients on ECMO. We did not identify a post-LTx survival difference between patients receiving ECMO when compared to those that did not. A multivariable Cox regression model (Hazard ratio = 0.83; 95% confidence interval: 0.47, 1.45; p = .51) did not demonstrate an increased risk for death post-LTx. Lastly, a propensity score matching analysis, retaining 33 ECMO and 33 non-ECMO patients, further confirmed no post-LTx survival difference comparing ECMO to no ECMO cohorts (Hazard ratio = 0.98; 95% confidence interval: 0.48, 2.00; p = .96).

CONCLUSIONS

In this contemporary cohort of children, the use of ECMO at the time of LTx did not negatively impact post-transplant survival.

The intersection of race and ethnicity, gender, and primary diagnosis on lung transplantation outcomes

BACKGROUND

Reducing racial disparities in lung transplant outcomes is a current priority of providers, policymakers, and lung transplant centers. It is unknown how the combined effect of race and ethnicity, gender, and diagnosis group is associated with differences in 1-year mortality and 5-year survival.

METHODS

This is a longitudinal cohort study using Standard Transplant Analysis Research files from the United Network for organ sharing. A total of 25,444 patients undergoing first time lung transplantation between 2006 and 2019 in the United States. The primary exposures were lung transplant recipient race and ethnicity, gender, and primary diagnosis group at listing. Multivariable regression models and cox-proportional hazards models were used to determine adjusted 1-year mortality and 5-year survival.

RESULTS

Overall, 25,444 lung transplant patients were included in the cohort including 15,160 (59.6%) men, 21,345 (83.9%) White, 2,318 (9.1%), Black and Hispanic/Latino (7.0%). Overall, men had a significant higher 1-year mortality than women (11.87%; 95% CI 11.07-12.67 vs 12.82%; 95% CI 12.20%-13.44%). Black women had the highest mortality of all race and gender combinations (14.51%; 95% CI 12.15%-16.87%). Black patients with pulmonary vascular disease had the highest 1-year mortality (19.77%; 95% CI 12.46%-27.08%) while Hispanic/Latino patients with obstructive lung disease had the lowest (7.42%; 95% CI 2.8%-12.05%). 5-year adjusted survival was highest among Hispanic/Latino patients (62.32%) compared to Black (57.59%) and White patients (57.82%).

CONCLUSIONS

There are significant differences in 1-year and 5-year mortality between and within racial and ethnic groups depending on gender and primary diagnosis. This demonstrates the impact of social and clinical factors on lung transplant outcomes.

Conditional Survival in Lung Transplantation: An Organ Procurement and Transplantation Network Database Analysis

Lung transplantation survival estimates are traditionally reported as fixed 1-, 5-, and 10-year mortality rates. Alternatively, this study aims to demonstrate how conditional survival models can provide useful prognostic information tailored to the time a recipient has already survived from the date of transplantation. Recipient data was obtained from the Organ Procurement and Transplantation Network database. Data from 24,820 adult recipients over age 18 who received a lung transplant between 2002 and 2017 were included in the study. Five-year observed conditional survival estimates were calculated by recipient age, sex, race, transplant indication, transplant type ( i.e. , single or double), and renal function at the time of transplantation. Significant variability exists in conditional survival following lung transplantation. Each specific recipient characteristic significantly impacted conditional survival during at least one time point in the first 5 years. Younger age and double lung transplantation were the two most positive predictors of improved conditional survival consistently throughout the 5-year study period. Conditional survival in lung transplantation recipients changes over time and across recipient characteristics. Hazards of mortality are not fixed and need to be dynamically evaluated as a function of time. Conditional survival calculations can provide more accurate prognostic predictions than unconditional survival estimates.

Factors Associated with Health-Related Quality of Life in Lung Transplant Candidates and Recipients

OBJECTIVES

Health-related quality of life has been well studied across transplantation fields, but factors associated with lung transplant preoperative and postoperative quality of life remain unknown. Here, we determine factors associated with health-related quality of life in lung transplant candidates and recipients to identify patients at risk of lower health-related quality of life.

MATERIALS AND METHODS

From January 2021 to May 2022, health-related quality of life was measured in candidates and recipients using the RAND 36-Item Short Form Health Survey questionnaire. We reviewed demographic parameters and clinical information and scored frailty according to the modified 5-item frailty index. We performed Fisher exact test and the Pearson chi-square test and used linear regression models to determine covariate associations on physical component summary, mental component summary, and self-reported health scores (α = 0.05).

RESULTS

Eleven candidates and 17 recipients comp-leted the survey. Compared with candidates, transplant recipients reported significantly higher scores in 4 of the 8 health domains and in the physical component summary (P < .01), mental component summary (P = .05), and self-reported health score (P < .01). In candidates, higher body mass index and higher modified 5-item frailty index scores were negatively associated with the physical component summary and mental component summary, respec-tively (P < .05). In recipients, higher body mass index and higher lung allocation scores were associated with lower values for the physical component summary (-2.29; P < .05) and self-reported health score (-0.33; P < .05), respectively.

CONCLUSIONS

Body mass index, the modified 5-item frailty index, and the lung allocation score were significantly associated with health-related quality of life in lung transplant recipients. Future interventions should target these modifiable associations to maximize candidate and recipient health-related quality of life.

Racial disparities in recommendations for surgical resection of primary brain tumours: a registry-based cohort analysis

BACKGROUND

Disparities in treatment and outcomes disproportionately affect minority ethnic and racial populations in many surgical fields. Although substantial research in racial disparities has focused on outcomes, little is known about how surgeon recommendations can be influenced by patient race. The aim of this study was to investigate racial and socioeconomic disparities in the surgical management of primary brain tumors.

METHODS

In this registry-based cohort study, we used data from the Surveillance, Epidemiology, and End Results (SEER) database (1975-2016) and the American College of Surgeons National Cancer Database (NCDB) in the USA for independent analysis. Adults (aged ≥20 years) with a new diagnosis of meningioma, glioblastoma, pituitary adenoma, vestibular schwannoma, astrocytoma, and oligodendroglioma, with information on tumour size and surgical recommendation were included in the analysis. The primary outcome of this study was the odds of a surgeon recommending against surgical resection at diagnosis of primary brain neoplasms. This outcome was determined using multivariable logistic regression with clinical, demographic, and socioeconomic factors.

FINDINGS

This study included US national data from the SEER (1975-2016) and NCDB (2004-17) databases of adults with a new diagnosis of meningioma (SEER n=63 674; NCDB n=222 673), glioblastoma (n=35 258; n=104 047), pituitary adenoma (n=27 506; n=87 772), vestibular schwannoma (n=11 525; n=30 745), astrocytoma (n=5402; n=10 631), and oligodendroglioma (n=3977; n=9187). Independent of clinical and demographic factors, including insurance status and rural-urban continuum code, Black patients had significantly higher odds of recommendation against surgical resection of meningioma (adjusted odds ratio 1·13, 95% CI 1·06-1·21, p<0·0001), glioblastoma (1·14, 1·01-1·28, p=0·038), pituitary adenoma (1·13, 1·05-1·22, p<0·0001), and vestibular schwannoma (1·48, 1·19-1·84, p<0·0001) when compared with White patients in the SEER dataset. Additionally, patients of unknown race had significantly higher odds of recommendation against surgical resection for pituitary adenoma (1·80, 1·41-2·30, p<0·0001) and vestibular schwannoma (1·49, 1·10-2·04, p=0·011). Performing a validation analysis using the NCDB dataset confirmed these significant results for Black patients with meningioma (1·18, 1·14-1·22, p<0·0001), glioblastoma (1·19, 1·12-1·28, p<0·0001), pituitary adenoma (1·21, 1·16-1·25, p<0·0001), and vestibular schwannoma (1·19, 1·04-1·35, p=0·0085), and indicated and indicated that the findings are independent of patient comorbidities. When further restricted to the most recent decade in SEER, these inequities held true for Black patients, except those with glioblastoma (meningioma [1·18, 1·08-1·28, p<0·0001], pituitary adenoma [1·20, 1·09-1·31, p<0·0001], and vestibular schwannoma [1·54, 1·16-2·04, p=0·0031]).

INTERPRETATION

Racial disparities in surgery recommendations in the USA exist for patients with primary brain tumours, independent of potential confounders including clinical, demographic, and select socioeconomic factors. Further studies are needed to understand drivers of this bias and enhance equality in surgical care.

FUNDING

None.

Racial and socioeconomic disparities in pediatric heart transplant outcomes in the era of anti-thymocyte globulin induction

BACKGROUND

Black race is associated with worse outcomes across solid organ transplantation. Augmenting immunosuppression through antithymocyte globulin (ATG) induction may mitigate organ rejection and graft loss. We investigated whether racial and socioeconomic outcome disparities persist in children receiving ATG induction.

METHODS

Using the Pediatric Heart Transplant Society registry, we compared outcomes in Black and White children who underwent heart transplant with ATG induction between 2000 and 2020. The primary outcomes of treated rejection, rejection with hemodynamic compromise (HC), and graft loss (death or re-transplant). We explored the association of these outcomes with race and socioeconomic disparity, assessed using a neighborhood deprivation index [NDI] score at 1-year post-transplant (high NDI score implies more socioeconomic disadvantage).

RESULTS

The study cohort included 1,719 ATG-induced pediatric heart transplant recipients (22% Black, 78% White). There was no difference in first year treated rejection (Black 24.5%, White 28.1%, p = 0.2). During 10 year follow up, the risk of treated rejection was similar; however, Black recipients were at higher risk of HC rejection (p = 0.009) and graft loss (p = 0.02). Black recipients had a higher mean NDI score (p < 0.001). Graft loss conditional on 1-year survival was associated with high NDI score in both White and Black recipients (p < 0.0001). In a multivariable Cox model, both high NDI score (HR 1.97, 95% CI 1.23-3.17) and Black race (HR 2.22, 95% CI 1.40-3.53) were associated with graft loss.

CONCLUSION

Black race and socioeconomic disadvantage remain associated with late HC rejection and graft loss in children with ATG induction. These disparities represent important opportunities to improve long term transplant outcomes.

The effect of the cystic fibrosis care center on outcomes after lung transplantation for cystic fibrosis

BACKGROUND

The purpose of this study was to evaluate outcomes in people with cystic fibrosis (CF) who underwent lung transplant (LT) at a transplant center with an accredited Cystic Fibrosis Care Center (CFCC) in the United States.

METHODS

We reviewed the Scientific Registry of Transplant Recipients for all adult patients with CF who received a first-time LT from 2005 to 2018. The primary outcome was graft failure. Unadjusted Kaplan-Meier analysis and adjusted multilevel Cox proportional hazards models were used to evaluate outcomes in CF patients undergoing lung transplantation at a CFCC.

RESULTS

2,573 patients with CF underwent a first time LT during the study period. Of the 68 lung transplantation centers, 50 were CFCCs (73.5%). After adjustment for potential confounders, patients who underwent lung transplantation at a hospital with an accredited CFCC had a 33% reduction in risk of death or re-transplantation compared to those transplanted at a hospital without an accredited CFCC (HR: 0.67, 95% CI: 0.56-0.82, p < 0.001).

CONCLUSIONS

People with CF who undergo LT at a transplant center with a CFCC have improved graft survival and decreased need for re-transplantation compared to those who undergo LT at a non-CFCC, independent of volume.

Disparities in Lung Transplantation

Since the initial report of long-term survival after lung transplantation (LT) in 1983, there has been remarkable progress in the field and LT is now the gold-standard therapy for patients with end-stage lung disease. It confers a significant survival advantage and improves the quality of life in patients who often have few other treatment options. However, LT remains a complex undertaking and establishing and maintaining an LT program is resource intensive with multiple potential barriers. In this article, we focus on disparities in LT and the potential solutions to improving access to LT.

Gender and racial disparities in lung transplantation in the United States

BACKGROUND

Lung transplant (LT) allocation utilizes a scoring system to prioritize patients, although data evaluating the access by gender and race remains limited. The study objective was to determine whether gender and racial disparities exist in patients listed for LT.

METHODS

This was a retrospective analysis using the Organ Procurement and Transplant Network database of patients listed for a LT from 1984 until 2019. Nominal multivariate logistic regression analysis was performed to evaluate LT allocation by gender, race, and primary lung disease. Kaplan-Meier curves were constructed to compare rates of mortality over time.

RESULTS

Sixty thousand eight hundred and forty-seven patients were listed between February 1984 and September 2019. Males comprised the majority of listed and transplanted patients at 51.7% and 55.8% respectively. In the LAS era, the median waiting list time for transplanted males was 43 days (interquartile range [IQR] 13-126), and females waited a median of 80 days (IQR 24-233) (p < .001). Persons of White race accounted for 82.6% and 84.3% of listed and transplanted patients respectively. Logistic regression analysis found that in the LAS era, males had an increased odds for LT allocation (OR 1.19, CI 1.12-1.27, p < .001) compared to females, and persons of White race (OR 1.23, CI 1.16-1.32, p < .001) compared to all other races combined.

CONCLUSIONS

The majority of listed and transplanted patients in the United States were males and persons of White race. Also, being a male or person of White race had an outcome favoring lung transplant allocation compared to an appropriately matched person of another gender or race.

Emergency Department Visits Among Lung Transplant Patients: A 4-Year Experience

BACKGROUND

Emergency department (ED) visits by lung transplant (LT) patients have not been well documented in the literature.

OBJECTIVES

To analyze outcomes among LT recipients with ED visits, to better inform clinicians regarding evaluation and treatment.

METHODS

This was a retrospective cohort study of LT patients at our ED (2015-2018). Demographics, transplant indication, laboratory studies, ED interventions, disposition, death, and revisit data were collected. Logistic regression models were used to identify univariable and multivariable predictors of ED revisit, intensive care unit (ICU) admission, or death.

RESULTS

For 505 ED visits among 160 LT recipients, respiratory-related concerns were most frequent (n = 152, 30.1%). Infection was the most common ED diagnosis (n = 101, 20.0%). Many patients were sent home from the ED (n = 235, 46.5%), and 31.3% (n = 158) returned to the ED within 30 days. Fourteen patients (2.8%) needed advanced airway measures. One patient died in the ED, and 18 died in the hospital. On multivariable analysis, more previous ED visits significantly increased the probability of 30-day ED revisit. Heart rate faster than 100 beats/min and systolic blood pressure < 90 mm Hg were significantly associated with ICU admission or death.

CONCLUSION

Infection should be prominent on the differential diagnosis for LT patients in the ED. A large proportion of patients were discharged from the ED, but a higher number of previous ED visits was most predictive of ED revisit within 30 days. Mortality rate was low in our study, but higher heart rate and lower systolic blood pressure were associated with ICU admission or death.

Access to Lung Transplantation in the United States: The Potential Impact of Access to a High-volume Center

BACKGROUND

Health disparities plague our healthcare system. Utilizing a novel approach, we sought to assess the effects of geographic disparities on access to lung transplantation (LT) in the United States.

METHODS

A total of 13 743 LT adult recipients in the United Network for Organ Sharing Database were identified between May 2005 and December 2014 with a zip code status. Geographic access was defined by global spherical distance from patient zip code centroid to transplant center. Measures analyzed included the association among socioeconomic status (SES), distance to a transplant center, and center switching behavior.

RESULTS

Median distance traveled was 62.9 miles. There was an inverse relationship between Diez Roux SES and median distance traveled (90 versus 80.1 versus 60.5 versus 30, P < 0.001). There was no association found between 5-y survival and distance traveled (P = 0.099). However, traveling >158.7 miles was associated with worse survival (hazard ration 1.1; 95% confidence interval, 1.0-1.2; P = 0.005). Over 80% of patients exhibiting center switching were transplanted at a high-volume center than their home institution. Those more likely to switch to a high-volume center were those with an associates/bachelor (P < 0.005) or graduate-level degree (P < 0.05). Recipients with high-volume home institutions had the lowest probability of switching to an alternative center (odds ratio, 0.009; P < 0.001). There was no difference in survival when comparing those transplanted at their home institution versus those who sought transplantation at an alternative institution (55.3% versus 55.0%, P = 0.41).

CONCLUSIONS

Although there was no association among SES, distance traveled, and survival, access to LT services varies among populations in the United States.

Future direction of immunosuppression in lung transplantation

PURPOSE OF REVIEW

Immunosuppression regimens have helped improve rejection episodes following lung transplantation, but long-term outcomes are still not comparable with cardiac, hepatic, or renal transplantation. This review summarizes the immunobiology that contributes to rejection events and future opportunities in outcomes on the basis of providing optimized delivery of the immunosuppression based on immune-monitoring techniques, taking into account individual patient pharmacokinetics and phenotypic variance.

RECENT FINDINGS

Drug toxicities, narrow therapeutic drug monitoring windows, and current immunoassays currently do not assist in detecting the global degree of immunosuppression. The currently available randomized control trials for induction therapy or maintenance therapies do not provide additional benefits compared with previously reported retrospective trials. To push beyond the current barriers, transplant teams are focusing on the role of pharmacokinetics, assessing phenotypic variable to potentially modify to quadruple therapy and using extracorporeal photopheresis.

SUMMARY

Conventional practice for the choices of immunosuppression is being evaluated on the basis of randomized control trials as opposed to retrospective studies or single-center trials. The future direction of immunosuppression will be continued by dynamic processes taking into consideration measures to improve tolerance, reducing treatment burden, and providing the best level of evidence while accounting for rejection, infections, renal function, and other comorbidities.

Racial disparities in outcomes of spinal surgery for lumbar stenosis

STUDY DESIGN

A retrospective, cross-sectional study.

OBJECTIVE

To evaluate racial disparities in outcomes of lumbar stenosis surgery.

SUMMARY OF BACKGROUND DATA

Racial inequalities have been described in the outcomes of cardiovascular and orthopedic procedures. There have been minimal investigation of racial disparities in complications and costs of lumbar laminectomies and fusions.

METHODS

We analyzed the Medicaid data set of Thomson Reuter's MarketScan database. African-American and non-Hispanic white patients who underwent laminectomy or fusion for lumbar stenosis with at least 2 years postoperative data were included. We examined the effect of race on the rate of reoperations, complications, and the cost associated with surgery.

RESULTS

African-American patients in the Medicaid database were at no higher risk for reoperation in the 2 years after an operation for lumbar stenosis than white patients (7.14% vs. 7.89%, P = 0.7895). However, we did find that African-American patients were more likely to experience postoperative complications of any kind, even after adjusting for length of hospital stay, comorbidities, sex, and age (adjusted odds ratio = 1.819, P = 0.0123 for immediate complication; adjusted odds ratio = 1.746, P = 0.0141 for 30-d complication; and adjusted odds ratio = 1.611, P = 0.0410 for 90-d complication). White patients had a significantly shorter length of stay (3 vs. 5 d, P < 0.007) and accrued fewer hospital-related costs ($16,148 vs. $24,267, P < 0.0007). African-American patients, despite having more comorbidities in our sample, were prescribed significantly fewer medications in the 2 years after index procedures (91 vs. 138 prescriptions, P < 0.0007) and had fewer medication costs during the 2 years after surgery ($5297 vs. $8450, P < 0.0007).

CONCLUSION

At the national level, there are several racial disparities in the rate of complications, length of stay, and costs after surgery for lumbar spinal stenosis.

LEVEL OF EVIDENCE

3.

Disparities in lung transplantation before and after introduction of the lung allocation score

BACKGROUND

In May 2005, the Lung Allocation Score (LAS) became the primary method for determining allocation of lungs for organ transplantation for those at least 12 years of age in the United States. During the pre-LAS period, black patients were more likely than white patients to become too sick or die while awaiting transplant. The association between gender and lung transplant outcomes has not been widely studied.

METHODS

Black and white patients aged ≥ 18 years registered on the United Network for Organ Sharing (UNOS) lung transplantation waiting list from January 1, 2000, to May 3, 2005 (pre-LAS, n = 8,765), and from May 4, 2005, to September 4, 2010 (LAS, n = 8,806), were included. Logistic regression analyses were based on smaller cohorts derived from patients listed in the first 2 years of each era (2,350 pre-LAS, and 2,446 LAS) to allow for follow-up time. Lung transplantation was the primary outcome measure. Multivariable analyses were performed within each interval to determine the odds that a patient would die or receive a lung transplant within 3 years of listing.

RESULTS

In the pre-LAS era, black patients were more likely than white patients to become too sick for transplantation or die within 3 years of waiting list registration (43.8% vs 30.8%; odds ratio [OR], 1.84; p < 0.001). Race was not associated with death or becoming too sick while listed for transplantation in the LAS era (14.0% vs 13.3%; OR, 0.93; p = 0.74). Black patients were less likely to undergo transplantation in the pre-LAS era (56.3% vs 69.2%; OR, 0.54; p < 0.001) but not in the LAS era (86.0% vs 86.7%; OR, 1.07; p = 0.74). Women were more likely than men to die or become too sick for transplantation within 3 years of listing in the LAS era (16.1% vs 11.3%; OR, 1.58; p < 0.001) compared with the pre-LAS era (33.4% vs 30.7%; OR, 1.19; p = 0.08).

CONCLUSION

Racial disparities in lung transplantation have decreased with the implementation of LAS as the method of organ allocation; however, gender disparities may have actually increased in the LAS era.