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Harding JL, Dixon MA, Di M, Hogan J, Pastan SO, Patzer RE. Setting reasonable goals for kidney transplant referral among dialysis facilities. BMC Nephrol 2024; 25:235. [PMID: 39048955 PMCID: PMC11270779 DOI: 10.1186/s12882-024-03671-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 07/15/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Determining whether a patient is eligible for kidney transplantation is complex. In this study, we estimate what proportion of patients with end-stage kidney disease (ESKD) might have been suitable candidates for kidney transplantation but were not referred. METHODS We identified 43,952 people initiating dialysis for kidney failure between 2012 and 2017 in the states of Georgia, North Carolina, or South Carolina from the United States Renal Data System and linked to the Early-Steps to Transplant Access Registry to obtain data on referral and waitlisting up until December 2020. We identified 'good transplant candidates' as those who were waitlisted within 2-years of referral, among all patients referred within 1-year of dialysis initiation. Using propensity score cut-offs, logistic regression, and area under the curve (AUC), we then estimated the proportion of individuals who may have been good transplant candidates, but were not referred. RESULTS Overall, 42.6% of incident dialysis patients were referred within one year and among them, 32.9% were waitlisted within 2 years of referral. Our model had reasonably good discrimination for identifying good transplant candidates with an AUC of 0.70 (95%CI 0.69-0.71), sensitivity of 0.68 and specificity of 0.61. Overall, 25% of individuals not referred for transplant may have been 'good' transplant candidates. Adding these patients to the existing 18,725 referred patients would increase the proportion of incident ESKD patients being referred within one year from 42.6% to 57.2% (a ~ 14.6% increase). CONCLUSIONS In this study, we show that a significant proportion of potentially good transplant candidates are not being referred for transplant. A ~ 14% increase in the proportion of patients being referred from dialysis facilities is both a meaningful and realistic goal and could lead to more qualified patients being referred and subsequently waitlisted for a lifesaving transplant.
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Affiliation(s)
- Jessica L Harding
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, 30322, USA.
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, 30322, USA.
- Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA.
| | - Meredith A Dixon
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Mengyu Di
- Regenstrief Institute, Indianapolis, IN, USA
| | - Julien Hogan
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, 30322, USA
- Division of Pediatric Nephrology Université Paris, Cité | Hôpital Robert Debré, APHP, Paris, France
| | - Stephen O Pastan
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Rachel E Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, 30322, USA
- Regenstrief Institute, Indianapolis, IN, USA
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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2
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Harding JL, Gompers A, Di M, Drewery K, Pastan S, Rossi A, DuBay D, Gander JC, Patzer RE. Sex/Gender Disparities in Preemptive Referrals for Kidney Transplantation. Kidney Int Rep 2024; 9:2134-2145. [PMID: 39081771 PMCID: PMC11284440 DOI: 10.1016/j.ekir.2024.04.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction Sex/gender inequities persist in access to kidney transplantation. Whether differences in preemptive referral (i.e., referral before dialysis start) explain this inequity remains unknown. Methods All adults (aged 18-79 years; N = 44,204) initiating kidney replacement therapy (KRT; dialysis or transplant) in Georgia (GA), North Carolina (NC), or South Carolina (SC) between 2015 and 2019 were identified from the United States Renal Data System (USRDS). Individuals were linked to the Early Steps to Kidney Transplant Access Registry (E-STAR) to obtain data on preemptive referral and followed-up with through November 13, 2020, for outcomes of waitlisting and living donor transplant. Logistic regression assessed the association between sex/gender and likelihood of preemptive referral among all KRT patients. Cox-proportional hazards assessed the association between sex/gender and waitlisting or living donor among preemptively referred patients. Results Overall, men and women were similarly likely to be preemptively referred (odds ratio [OR]: 0.99 [0.95-1.04]). Preemptively referred women (vs. men) were, on average, younger and with fewer comorbidities. There were no sex/gender differences in waitlisting once patients were preemptively referred (hazard ratio [HR]: 0.97 [0.91-1.03]); however, women (vs. men) who were preemptively referred remained 25% (HR: 0.75 [0.66-0.86]) less likely to receive a living donor transplant. Conclusion In the Southeast US, men and women initiating KRT are similarly likely to be preemptively referred for a kidney transplant, and this appears, at least in part, to mitigate known sex/gender inequities in access to waitlisting, but not living donor transplant. Despite this, preemptively referred women, on average, had a more favorable medical profile relative to preemptively referred men.
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Affiliation(s)
- Jessica L. Harding
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Annika Gompers
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Mengyu Di
- William M. Tierney Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana, USA
| | - Kelsey Drewery
- Department of Surgery, School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Stephen Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, Georgia, USA
| | - Derek DuBay
- Prisma Healthcare, Charleston, South Carolina, USA
| | - Jennifer C. Gander
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Rachel E. Patzer
- Department of Surgery, School of Medicine, Indiana University, Indianapolis, IN, USA
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Patzer RE. Bridging Racial Disparities in Access to Kidney Transplantation in the United States: Glass Part-Empty or Part-Full? J Am Soc Nephrol 2024; 35:959-961. [PMID: 38985123 PMCID: PMC11230722 DOI: 10.1681/asn.0000000000000366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024] Open
Affiliation(s)
- Rachel E Patzer
- Regenstrief Institute, Indianapolis, Indiana, and Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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4
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Stewart D, John P. Fully Understanding Sex/Gender Disparities in Kidney Care Requires End-to-End, National Data Collection. Kidney Int Rep 2024; 9:1951-1953. [PMID: 39081749 PMCID: PMC11284399 DOI: 10.1016/j.ekir.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024] Open
Affiliation(s)
- Darren Stewart
- Department of Surgery, NYU Langone Health, New York, USA
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5
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Nishio Lucar AG, Patel A, Mehta S, Yadav A, Doshi M, Urbanski MA, Concepcion BP, Singh N, Sanders ML, Basu A, Harding JL, Rossi A, Adebiyi OO, Samaniego-Picota M, Woodside KJ, Parsons RF. Expanding the access to kidney transplantation: Strategies for kidney transplant programs. Clin Transplant 2024; 38:e15315. [PMID: 38686443 DOI: 10.1111/ctr.15315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/05/2024] [Accepted: 03/28/2024] [Indexed: 05/02/2024]
Abstract
Kidney transplantation is the most successful kidney replacement therapy available, resulting in improved recipient survival and societal cost savings. Yet, nearly 70 years after the first successful kidney transplant, there are still numerous barriers and untapped opportunities that constrain the access to transplant. The literature describing these barriers is extensive, but the practices and processes to solve them are less clear. Solutions must be multidisciplinary and be the product of strong partnerships among patients, their networks, health care providers, and transplant programs. Transparency in the referral, evaluation, and listing process as well as organ selection are paramount to build such partnerships. Providing early culturally congruent and patient-centered education as well as maximizing the use of local resources to facilitate the transplant work up should be prioritized. Every opportunity to facilitate pre-emptive kidney transplantation and living donation must be taken. Promoting the use of telemedicine and kidney paired donation as standards of care can positively impact the work up completion and maximize the chances of a living donor kidney transplant.
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Affiliation(s)
- Angie G Nishio Lucar
- Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
| | - Ankita Patel
- Recanati-Miller Transplantation Institute, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shikha Mehta
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Anju Yadav
- Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mona Doshi
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Megan A Urbanski
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Neeraj Singh
- Willis Knighton Health System, Shreveport, Louisiana, USA
| | - M Lee Sanders
- Department of Internal Medicine, Division of Nephrology, Organ Transplant Center, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Arpita Basu
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jessica L Harding
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, Georgia, USA
| | - Oluwafisayo O Adebiyi
- Department of Medicine, Indiana University Health Hospital, Indianapolis, Indiana, USA
| | | | | | - Ronald F Parsons
- Department of Surgery, University of Pennsylvannia, Philadelphia, Pennsylvania, USA
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Harding JL, Di M, Pastan SO, Doucet N, Rossi A, DuBay D, Rice T, Patzer RE. Examination of sex/gender disparities across the continuum of kidney transplant steps. Nephrol Dial Transplant 2024; 39:717-719. [PMID: 37950570 PMCID: PMC11024813 DOI: 10.1093/ndt/gfad242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Indexed: 11/12/2023] Open
Affiliation(s)
- Jessica L Harding
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
- Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Mengyu Di
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
- Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Stephen O Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, GA, USA
| | - Nicole Doucet
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, GA, USA
| | - Derek DuBay
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Teresa Rice
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Rachel E Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
- Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA
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7
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Urbanski M, Lee YTH, Escoffery C, Buford J, Plantinga L, Pastan SO, Hamoda R, Blythe E, Patzer RE. Implementation of the ASCENT Trial to Improve Transplant Waitlisting Access. Kidney Int Rep 2024; 9:225-238. [PMID: 38344743 PMCID: PMC10851002 DOI: 10.1016/j.ekir.2023.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 10/23/2023] [Accepted: 10/30/2023] [Indexed: 04/28/2024] Open
Abstract
Introduction The Allocation System for changes in Equity in Kidney Transplantation (ASCENT) study was a hybrid type 1 trial of a multicomponent intervention among 655 US dialysis facilities with low kidney transplant waitlisting to educate staff and patients about kidney allocation system (KAS) changes and increase access to and reduce racial disparities in waitlisting. Intervention components included a staff webinar, patient and staff educational videos, and facility-specific feedback reports. Methods Implementation outcomes were assessed using the Reach, Effectiveness, Adoption, Implementation, and Maintenance Framework. Postimplementation surveys were administered among intervention group facilities (n = 334); interviews were conducted with facility staff (n = 6). High implementation was defined as using 3 to 4 intervention components, low implementation as using 1 to 2 components, and nonimplementation as using no components. Results A total of 331 (99%) facilities completed the survey; 57% were high implementers, 31% were low implementers, and 12% were nonimplementers. Waitlisting events were higher or similar among high versus low implementer facilities for incident and prevalent populations; for Black incident patients, the mean proportion waitlisted in low implementer facilities was 0.80% (95% confidence interval [CI]: 0.73-0.87) at baseline and 0.55% at 1-year (95% CI: 0.48-0.62) versus 0.83% (95% CI: 0.78-0.88) at baseline and 1.40% at 1-year (95% CI: 1.35-1.45) in high implementer facilities. Interviews revealed that the intervention helped facilities prioritize transplant education, but that intervention components were not uniformly shared. Conclusion The findings provide important context to interpret ASCENT effectiveness results and identified key barriers and facilitators to consider for future modification and scale-up of multilevel, multicomponent interventions in dialysis settings.
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Affiliation(s)
- Megan Urbanski
- Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
- Health Services Research Center, Emory University, Atlanta, Georgia, USA
| | - Yi-Ting Hana Lee
- Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Cam Escoffery
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Jade Buford
- Regenstrief Institute, Indianapolis, Indiana, USA
| | - Laura Plantinga
- University of California San Francisco, Department of Medicine, Divisions of Rheumatology and Nephology, San Francisco, California, USA
| | - Stephen O. Pastan
- Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Reem Hamoda
- Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Emma Blythe
- Health Services Research Center, Emory University, Atlanta, Georgia, USA
| | - Rachel E. Patzer
- Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
- Regenstrief Institute, Indianapolis, Indiana, USA
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana, USA
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8
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Purtell L, Bennett P, Bonner A. Multimodal approaches for inequality in kidney care: turning social determinants of health into opportunities. Curr Opin Nephrol Hypertens 2024; 33:34-42. [PMID: 37847046 DOI: 10.1097/mnh.0000000000000936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
PURPOSE OF REVIEW Kidney disease is associated with major health and economic burdens worldwide, disproportionately carried by people in low and middle socio-demographic index quintile countries and in underprivileged communities. Social determinants such as education, income and living and working conditions strongly influence kidney health outcomes. This review synthesised recent research into multimodal interventions to promote kidney health equity that focus on the social determinants of health. RECENT FINDINGS Inequity in kidney healthcare commonly arises from nationality, race, sex, food insecurity, healthcare access and environmental conditions, and affects kidney health outcomes such as chronic kidney disease progression, dialysis and transplant access, morbidity and mortality. Multimodal approaches to addressing this inequity were identified, targeted to: patients, families and caregivers (nutrition, peer support, financial status, patient education and employment); healthcare teams (workforce, healthcare clinician education); health systems (data coding, technology); communities (community engagement); and health policy (clinical guidelines, policy, environment and research). SUMMARY The engagement of diverse patients, families, caregivers and communities in healthcare research and implementation, as well as clinical care delivery, is vital to counteracting the deleterious effects of social determinants of kidney health.
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Affiliation(s)
- Louise Purtell
- School of Nursing and Midwifery
- Menzies Health Institute Queensland, Griffith University
- Research Development Unit, Caboolture Hospital, Metro North Health
- Kidney Health Service, Metro North Health, Queensland, Australia
| | - Paul Bennett
- School of Nursing and Midwifery
- Menzies Health Institute Queensland, Griffith University
| | - Ann Bonner
- School of Nursing and Midwifery
- Menzies Health Institute Queensland, Griffith University
- Kidney Health Service, Metro North Health, Queensland, Australia
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Harding JL, Di M, Pastan SO, Rossi A, DuBay D, Gompers A, Patzer RE. Sex/Gender-Based Disparities in Early Transplant Access by Attributed Cause of Kidney Disease-Evidence from a Multiregional Cohort in the Southeast United States. Kidney Int Rep 2023; 8:2580-2591. [PMID: 38106598 PMCID: PMC10719652 DOI: 10.1016/j.ekir.2023.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/14/2023] [Accepted: 09/04/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction We examined sex/gender disparities across the continuum of transplant care by attributed cause of end-stage kidney disease (ESKD). Methods All adults (18-79 years; N = 43,548) with new-onset ESKD in Georgia, North Carolina, or South Carolina between 2015 and 2019 were identified from the United States Renal Data System (USRDS). Individuals were linked to the Early Steps to Transplant Access Registry (E-STAR) to obtain data on referral and evaluation. Waitlisting data was ascertained from USRDS. Using a Cox-proportional hazards model, with follow-up through 2020, we assessed the association between sex/gender and referral within 12 months (among all incident dialysis patients), evaluation start within 6 months (among referred patients), and waitlisting (among all evaluated patients) by attributed cause of ESKD (type 1 diabetes mellitus, type 2 diabetes mellitus, hypertension, glomerulonephritis, cystic disease, and other). Results Overall, women (vs. men) with type 2 diabetes-attributed ESKD were 13% (crude hazard ratio [HR]: 0.87 [0.83-0.91]), 14% (crude HR: 0.86 [0.81-0.91]), and 14% (crude HR: 0.86 [0.78-0.94]) less likely to be referred, evaluated, and waitlisted, respectively. Women (vs. men) with hypertension-attributed ESKD were 14% (crude HR: 0.86 [0.82-0.90]) and 8% (crude HR: 0.92 [0.87-0.98]) less likely to be referred and evaluated, respectively, but similarly likely to be waitlisted once evaluated (crude HR: 1.06 [0.97-1.15]). For all other attributed causes of ESKD, there was no sex/gender disparity in referral, evaluation, or waitlisting rates. Conclusion In the Southeast United States, sex/gender disparities in early access to kidney transplantation are specific to people with ESKD attributed to type 2 diabetes and hypertension.
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Affiliation(s)
- Jessica L. Harding
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mengyu Di
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Stephen O. Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, Georgia, USA
| | - Derek DuBay
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Annika Gompers
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Rachel E. Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
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Harding CC, Ephraim PL, Davenport CA, McElroy LM, Mohottige D, DePasquale N, Lunyera J, Strigo TS, Pounds IA, Riley J, Alkon A, Ellis M, Boulware LE. Association of Age and Gender With Concerns About Live Donor Kidney Transplantation Among Black Individuals. Transplant Proc 2023; 55:2403-2409. [PMID: 37945446 PMCID: PMC10872540 DOI: 10.1016/j.transproceed.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/04/2023] [Indexed: 11/12/2023]
Abstract
Black individuals are less likely to receive live donor kidney transplantation (LDKT) compared to others. This may be partly related to their concerns about LDKT, which can vary based on age and gender. We conducted a cross-sectional, secondary analysis of the baseline enrollment data from the Talking about Living Kidney Donation Support trial, which studied the effectiveness of social workers and financial interventions on activation towards LDKT among 300 Black individuals from a deceased donor waiting list. We assessed concerns regarding the LDKT process, including their potential need for postoperative social support, future reproductive potential, recipient and donor money matters, recipient and donor safety, and interpersonal concerns. Answers ranged from 0 ("not at all concerned") to 10 ("extremely concerned"). We described and compared participants' concerns both overall and stratified by age (≥45 years old vs <45 years old) and self-reported gender ("male" versus "female"). The participants' top concerns were donor safety (median [IQR] score 10 [5-10]), recipient safety (5 [0-10]), money matters (5 [0-9]), and guilt/indebtedness (5 [0-9]). Younger females had statistically significantly higher odds of being concerned about future reproductive potential (odds ratio [OR] 3.77, 95% CI 2.77, 4.77), and older males had statistically higher mean concern about postoperative social support (OR 1.79, 95% CI 0.19, 3.38). Interventions to improve rates of LDKT among Black individuals should include education and counseling about the safety of LDKT for both recipients and donors, reproductive counseling for female LDKT candidates of childbearing age, and addressing older males' needs for increased social support.
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Affiliation(s)
- Ceshae C Harding
- General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Patti L Ephraim
- Institute of Health System Science, Feinstein Institute for Medical Research, Northwell Health, New York, New York
| | - Clemontina A Davenport
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Lisa M McElroy
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Dinushika Mohottige
- Institute for Health Equity Research, Department of Population Health, Icahn School of Medicine at Mount Sinai, New York, New York; Barbara T. Murphy Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nicole DePasquale
- General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Joseph Lunyera
- General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Tara S Strigo
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Iris A Pounds
- General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Jennie Riley
- General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Aviel Alkon
- General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Matthew Ellis
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - L Ebony Boulware
- Wake Forest University School of Medicine, Winston-Salem, North Carolina.
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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] [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.
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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
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12
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Chan NW, Moya-Mendez M, Henson JB, Zaribafzadeh H, Sendak MP, Bhavsar NA, Balu S, Kirk AD, McElroy LM. Social determinants of health data in solid organ transplantation: National data sources and future directions. Am J Transplant 2022; 22:2293-2301. [PMID: 35583111 PMCID: PMC9547872 DOI: 10.1111/ajt.17096] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/04/2022] [Accepted: 05/15/2022] [Indexed: 01/25/2023]
Abstract
Health equity research in transplantation has largely relied on national data sources, yet the availability of social determinants of health (SDOH) data varies widely among these sources. We sought to characterize the extent to which national data sources contain SDOH data applicable to end-stage organ disease (ESOD) and transplant patients. We reviewed 10 active national data sources based in the United States. For each data source, we examined patient inclusion criteria and explored strengths and limitations regarding SDOH data, using the National Institutes of Health PhenX toolkit of SDOH as a data collection instrument. Of the 28 SDOH variables reviewed, eight-core demographic variables were included in ≥80% of the data sources, and seven variables that described elements of social status ranged between 30 and 60% inclusion. Variables regarding identity, healthcare access, and social need were poorly represented (≤20%) across the data sources, and five of these variables were included in none of the data sources. The results of our review highlight the need for improved SDOH data collection systems in ESOD and transplant patients via: enhanced inter-registry collaboration, incorporation of standardized SDOH variables into existing data sources, and transplant center and consortium-based investigation and innovation.
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Affiliation(s)
- Norine W. Chan
- Duke University School of Medicine, Durham, North Carolina, USA,Duke Institute for Health Innovation, Durham, North Carolina, United States
| | | | - Jacqueline B. Henson
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Hamed Zaribafzadeh
- Duke Institute for Health Innovation, Durham, North Carolina, United States
| | - Mark P. Sendak
- Duke Institute for Health Innovation, Durham, North Carolina, United States
| | - Nrupen A. Bhavsar
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA,Department of Biostatistics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Suresh Balu
- Duke Institute for Health Innovation, Durham, North Carolina, United States
| | - Allan D. Kirk
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lisa M. McElroy
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA,Department of Population Health Sciences Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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13
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Patzer RE, Adler JT, Harding JL, Huml A, Kim I, Ladin K, Martins PN, Mohan S, Ross-Driscoll K, Pastan SO. A Population Health Approach to Transplant Access: Challenging the Status Quo. Am J Kidney Dis 2022; 80:406-415. [PMID: 35227824 DOI: 10.1053/j.ajkd.2022.01.422] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/09/2022] [Indexed: 01/27/2023]
Abstract
Transplant referral and evaluation are critical steps to waitlisting yet remain an elusive part of the transplant process. Despite calls for more data collection on pre-waitlisting steps, there are currently no national surveillance data to aid in understanding the causes and potential solutions for the extreme variation in access to transplantation. As population health scientists, epidemiologists, clinicians, and ethicists we submit that the transplant community has an obligation to better understand disparities in transplant access as a first necessary step to effectively mitigating these inequities. Our position is grounded in a population health approach, consistent with several new overarching national policy and quality initiatives. The purpose of this Perspective is to (1) provide an overview of how a population health approach should inform current multisystem policies impacting kidney transplantation and demonstrate how these efforts could be enhanced with national data collection on pre-waitlisting steps; (2) demonstrate the feasibility and concrete next steps for pre-waitlisting data collection; and (3) identify potential opportunities to use these data to implement effective population-level interventions, policies, and quality measures to improve equity in access to kidney transplantation.
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Affiliation(s)
- Rachel E Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
| | - Joel T Adler
- Department of Surgery, Division of Organ Transplantation, University of Massachusetts, Worcester, Massachusetts; Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jessica L Harding
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Anne Huml
- Case Center for Reducing Health Disparities, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Irene Kim
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Keren Ladin
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts; Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, Massachusetts
| | - Paulo N Martins
- Department of Surgery, Division of Organ Transplantation, University of Massachusetts, Worcester, Massachusetts
| | - Sumit Mohan
- Departments of Medicine and Epidemiology, Columbia University, New York, New York
| | - Katie Ross-Driscoll
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Stephen O Pastan
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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14
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Gender Disparities in Kidney Transplantation Referral Vary by Age and Race – A Multi-Regional Cohort Study in the Southeast US. Kidney Int Rep 2022; 7:1248-1257. [PMID: 35694555 PMCID: PMC9174037 DOI: 10.1016/j.ekir.2022.03.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 03/23/2022] [Accepted: 03/28/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Methods Results Conclusion
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