U.S. nephrologists' attitudes towards renal transplantation: results from a national survey

Impact of sex on the outcomes of deceased donor liver transplantation

BACKGROUND

Data examining the impact of sex on liver transplant (LT) outcomes are limited. It is clear that further research into sex-related differences in transplant patients is necessary to identify areas for improvement. Elucidation of these differences may help to identify specific areas of focus to improve on the organ matching process, as well as the peri- and post-operative care of these patients.

AIM

To utilize data from a high-volume Eurotransplant center to compare characteristics of male and female patients undergoing liver transplant and assess asso ciation between sex-specific variables with short- and long-term post-transplant outcomes.

METHODS

A retrospective review of the University of Essen's transplant database was performed with collection of baseline patient characteristics, transplant-related data, and short-term outcomes. Comparisons of these data were made with Shapiro-Wilk, Mann-Whitney U, χ2 and Bonferroni tests applied where app ropriate. A P value of < 0.05 was accepted as statistically significant.

RESULTS

Of the total 779 LT recipients, 261 (33.5%) were female. Female patients suffered higher incidences of acute liver failure and lower incidences of alcohol-related or viremic liver disease (P = 0.001). Female patients were more likely to have received an organ from a female donor with a higher donor risk index score, and as a high urgency offer (all P < 0.05). Baseline characteristics of male and female recipients were also significantly different. In multivariate hazard regression analysis, recipient lab-Model for End-Stage Liver Disease score and donor cause of death were associated with long-term outcomes in females. Pre-operative diagnosis of hepatocellular carcinoma, age at time of listing, duration of surgery, and units transfused during surgery, were associated with long-term outcomes in males. Severity of complications was associated with long-term outcomes in both groups. Overall survival was similar in both males and females; however, when stratified by age, females < 50 years of age had the best survival.

CONCLUSION

Female and male LT recipients have different baseline and transplant-related characteristics, with sex-specific variables which are associated with long-term outcomes. Female recipients < 50 years of age demonstrated the best long-term outcomes. Pre- and post-transplant practices should be individualized based on sex-specific variables to optimize long-term outcomes.

Intersectional race and gender disparities in kidney transplant access in the United States: a scoping review

BACKGROUND

Gender and racial disparities in kidney transplant access are well established, however how gender and race interact to shape access to kidney transplant is less clear. Therefore, we examined existing literature to assess what is known about the potential interaction of gender and race and the impact on access to kidney transplantation in the US.

METHODS

Following PRISMA guidelines, we conducted a scoping review and included quantitative and qualitative studies published in English between 1990 and May 31, 2023 among adult end-stage kidney disease patients in the US. All studies reported on access to specific transplant steps or perceived barriers to transplant access in gender and race subgroups, and the intersection between the two. We narratively synthesized findings across studies.

RESULTS

Fourteen studies met inclusion criteria and included outcomes of referral (n = 4, 29%), evaluation (n = 2, 14%), waitlisting (n = 4, 29%), transplantation (n = 5, 36%), provider perceptions of patient transplant candidacy (n = 3, 21%), and patient preferences and requests for a living donor (n = 5, 36%). Overall, we found that White men have the greatest access at all steps of the transplant process, from referral to eventual living or deceased donor transplantation. In contrast, women from racial or ethnic minorities tend to have the lowest access to kidney transplant, in particular living donor transplant, though this was not consistent across all studies.

CONCLUSIONS

Examining how racism and sexism interact to shape kidney transplant access should be investigated in future research, in order to ultimately shape policies and interventions to improve equity.

Women's Access to Kidney Transplantation in France: A Mixed Methods Research Protocol

Kidney transplantation is the best renal replacement therapy (medically and economically) for eligible patients with end-stage kidney disease. Studies in some French regions and in other countries suggest a lower access to the kidney transplant waiting listing and also to kidney transplantation, once waitlisted, for women. Using a mixed methods approach, this study aims to precisely understand these potential sex disparities and their causes. The quantitative study will explore the geographic disparities, compare the determinants of access to the waiting list and to kidney transplantation, and compare the reasons and duration of inactive status on the waiting list in women and men at different scales (national, regional, departmental, and census-block). The qualitative study will allow describing and comparing women's and men's views about their disease and transplantation, as well as nephrologists' practices relative to the French national guidelines on waiting list registration. This type of study is important in the current societal context in which the reduction of sex/gender-based inequalities is a major social expectation.

Israeli Medical Experts’ Knowledge, Attitudes, and Preferences in Allocating Donor Organs for Transplantation

Medical advancement has increased the confidence in successful organ transplants in end-stage patients. As the waitlist of organ demand is multiplying, the organ allocation process is becoming more crucial. In this situation, a transparent and efficient organ allocation policy is required. This study evaluates the preferences of medical experts to substantial factors for allocating organs in different hypothetical scenarios. Twenty-five medical professionals with a significant role in organ allocation were interviewed individually. The interview questionnaire comprised demographic information, organ donation status, important organ allocation factors, public preference knowledge, and experts’ preferences in different hypothetical scenarios. Most medical experts rated the waiting time and prognosis as the most important, while the next of kin donor status and care and contribution to the well-being of others were the least important factors for organ allocation. In expert opinion, medical experts significantly considered public preferences for organ allocation in making their decisions. Altogether, experts prioritized waiting time over successful transplant, age, and donor status in the hypothetical scenarios. In parallel, less chance of finding another organ, donor status, and successful transplant were prioritized over age. Medical experts are the key stakeholders; therefore, their opinions are substantial in formulating an organ allocation policy.

'As a surgeon, I am obliged to every single patient': evaluation of focus group discussions with transplantation physicians on the allocation of donor organs

INTRODUCTION

Organ transplantation is the last resort for many patients. The ubiquitous shortage of suitable donor organs raises the question of best-justifiable allocation worldwide. This study investigates how physicians would allocate donor organs.

METHODS

Focus group discussions with a total of 12 transplant surgeons and 2 other transplant-related physicians were held at the annual conference of the German Transplantation Society (Oct 2019). Three groups discussed aspects of 'egalitarianism', 'effectiveness/benefit', 'medical urgency', 'own fault', 'medical background' and 'socio-demographic status'.

RESULTS AND DISCUSSION

It was observed that physicians often find themselves confronted with conflicts between (a) trying to advocate for their individual patients versus (b) seeing the systemic perspective and understanding the global impact of their decisions at the same time. The groups agreed that due to the current shortage of donor organs in the German allocation system, transplanted patients are often too sick at the point of transplantation and that a better balance between urgency and effectiveness is needed. The aspects of 'effectiveness' and 'urgency' were identified as the most challenging issues and thus were the main focus of debate. The dilemmas physicians find themselves in become increasingly severe, the larger the shortage of suitable donor organs is.

Obesity and gender-biased access to deceased donor kidney transplantation

BACKGROUND

Despite the survival advantage of transplantation over dialysis, obese patients are less likely to be listed on the deceased donor waiting list and subsequently transplanted. This study aimed to determine the association between obesity and access to deceased donor transplantation and whether any association observed was applicable to men and women equally.

METHODS

Cox proportional hazards models were conducted to determine the association between obesity and waitlisting for transplantation and then subsequent receipt of a kidney transplant using data from the Australian and New Zealand Dialysis and Transplant Registry (2007-14).

RESULTS

Of 11633 patients included, 4408 (37.9%) were obese. Over a follow-up period of 26306 patient-years during waitlisting and 5607 patient-years from waitlisting to transplantation, 3515 candidates were listed (28.4% obese) and 1662 were transplanted (29.3% obese). Obesity was associated with a reduced likelihood of waitlisting {adjusted hazard ratio [aHR] 0.66 [95% confidence interval (CI) 0.58-0.76]} but not kidney transplantation once waitlisted [aHR 1.10 (95% CI 0.97-1.24)]. The impact of obesity and waitlisting was modified by gender (P-value for interaction = 0.01). Women who were obese were 34% less likely to be listed than normal-weight women [aHR 0.66 (95% CI 0.58-0.76)], compared with obese men who were 14% less likely [aHR 0.86 (95% CI 0.77-0.97)].

CONCLUSIONS

Overall, obesity reduces the likelihood of being listed for deceased donor transplantation, especially among women, but not transplantation once listed. Transplant physicians who regulate access to the deceased donor waiting list should be aware of this apparent inequity and seek to understand and ameliorate contributing factors.

Perioperative Considerations Regarding Sex in Solid Organ Transplantation

Sex plays a role in all stages of the organ transplant process, including listing, sex/size matching of organs, complications, graft survival, and mortality. Sex-related differences in organ transplantation are likely multifactorial related to biological and social characteristics. More information is needed to determine how sex-related differences can lead to improved outcomes for future donors and recipients of solid organs. This article provides an overview on the impact of sex on various types of solid organ transplant, including kidney, pancreas, liver, lung, and heart transplants.

Role of Physical Performance Assessments and Need for a Standardized Protocol for Selection of Older Kidney Transplant Candidates

The older adult population (65 years or older) with advanced or end-stage kidney disease is steadily growing, but rates of transplantation within this cohort have not increased in a similar fashion. Physical deconditioning, resulting in poor post-transplantation outcomes, is a primary concern among older renal patients. The assessment of physical function often holds more weight in the selection process for older candidates, despite evidence showing benefits of transplantation to this vulnerable population. Although several frailty assessment tools are being used increasingly to assess functional status, there is no standardized selection process for older candidates based on these assessment results. Also, it is unknown if timely targeted physical therapy interventions in older patients result in significant improvement of functioning capacity, translating to higher listing and transplantation rates, and improved post-transplantation outcomes. It is therefore of upmost importance not only to incorporate an effective objective functional status assessment process into selection and waitlist evaluation protocols, but also to have targeted interventions in place to maintain and improve physical conditioning among older renal patients. This paper reviews the commonly utilized assessment tools, and their applicability to older patients with renal disease. We also propose the need for definitive selection and waitlist management guidelines to formulate a streamlined assessment of functional capacity and transplant eligibility, as well as a process to maintain functional status, thereby increasing the access of older patients to renal transplantation.

Subclinical Cognitive Impairment and Listing for Kidney Transplantation

BACKGROUND AND OBJECTIVES

Cognitive impairment is common in patients with kidney disease and can affect physicians' perception and/or patients' ability to complete the pretransplant evaluation. We examined whether cognitive impairment influences the likelihood for transplant listing and whether patients with cognitive impairment take longer to be listed.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a single-center longitudinal cohort study. Patients presenting for their index kidney transplant evaluation were screened for cognitive impairment using the Montreal Cognitive Assessment. A score <26 indicated cognitive impairment. The transplant selection committee was blinded to the scores. Kaplan-Meier analysis assessed time to active listing by level of cognition. A Cox proportional hazards model that included age, sex, race/ethnicity, smoking, coronary artery disease, and diabetes was constructed to evaluate the association between Montreal Cognitive Assessment score and listing for transplant.

RESULTS

In total, 349 patients who underwent Montreal Cognitive Assessment testing at their initial visit were included in the analysis. Patients with cognitive impairment were more likely to be older, black, and smokers. The time to listing in patients with cognitive impairment was longer than the time to listing in those with no cognitive impairment (median time, 10.6 versus 6.3 months; log rank test P=0.01). Cognitive impairment was independently associated with a lower likelihood of being listed for transplant (hazard ratio, 0.93 per unit lower Montreal Cognitive Assessment score; 95% confidence interval, 0.88 to 0.99; P=0.02). A lower proportion of patients with cognitive impairment were listed compared with patients without cognitive impairment at 1 month (2% versus 11%), 6 months (17% versus 37%), and 1 year (23% versus 41%), (P<0.001 for all).

CONCLUSIONS

Cognitive impairment is associated with a lower likelihood of being listed for kidney transplant, and is associated with longer time to transplant listing.

Public, medical professionals' and patients' preferences for the allocation of donor organs for transplantation: study protocol for discrete choice experiments

INTRODUCTION

Organ transplantation is the treatment of choice for patients with severe organ failure. Nevertheless, donor organs are a scarce resource resulting in a large mismatch between supply and demand. Therefore, priority-setting leads to the dilemma of how these scarce organs should be allocated and who should be considered eligible to receive a suitable organ. In order to improve the supply-demand mismatch in transplantation medicine, this study explores preferences of different stakeholders (general public, medical professionals and patients) for the allocation of donor organs for transplantation in Germany. The aims are (1) to determine criteria and preferences, which are relevant for the allocation of scarce donor organs and (2) to compare the results between the three target groups to derive strategies for health policy.

METHODS AND ANALYSIS

We outline the study protocol for discrete choice experiments, where respondents are presented with different choices including attributes with varied attribute levels. They were asked to choose between these choice sets. First, systematic reviews will be conducted to identify the state of art. Subsequently, focus group discussions with the public and patients as well as expert interviews with medical professionals will follow to establish the attributes that are going to be included in the experiments and to verify the results of the systematic reviews. Using this qualitative exploratory work, discrete choice studies will be designed to quantitatively assess preferences. We will use a D-efficient fractional factorial design to survey a total sample of 600 respondents according to the public, medical professionals and patients each. Multinomial conditional logit model and latent class model will be analysed to estimate the final results.

ETHICS AND DISSEMINATION

This study has received Ethics Approval from the Hannover Medical School Human Ethics Committee (Vote number: 7921_BO_K_2018). Findings will be disseminated through conference presentations, workshops with stakeholders and peer-reviewed journal articles.

Gender Disparities in Access to Pediatric Renal Transplantation in Europe: Data From the ESPN/ERA-EDTA Registry

Inequalities between genders in access to transplantation have been demonstrated. We aimed to validate this gender inequality in a large pediatric population and to investigate its causes. This cohort study included 6454 patients starting renal replacement therapy before 18 years old, in 35 countries participating in the European Society for Paediatric Nephrology/European Renal Association-European Dialysis and Transplant Association Registry. We used cumulative incidence competing risk and proportional hazards frailty models to study the time to receive a transplant and hierarchical logistic regression to investigate access to preemptive transplantation. Girls had a slower access to renal transplantation because of a 23% lower probability of receiving preemptive transplantation. We found a longer follow-up time before renal replacement therapy in boys compared with girls despite a similar estimated glomerular filtration rate at first appointment. Girls tend to progress faster toward end-stage renal disease than boys, which may contribute to a shorter time available for pretransplantation workup. Overall, medical factors explained only 70% of the gender difference. In Europe, girls have less access to preemptive transplantation for reasons that are only partially related to medical factors. Nonmedical factors such as patient motivation and parent and physician attitudes toward transplantation and organ donation may contribute to this inequality. Our study should raise awareness for the management of girls with renal diseases.

Nephrologists' likelihood of referring patients for kidney transplant based on hypothetical patient scenarios

Background

There is wide variation in referral for kidney transplant and preemptive kidney transplant (PKT). Patient characteristics such as age, race, sex and geographic location have been cited as contributing factors to this disparity. We hypothesize that the characteristics of nephrologists interplay with the patients' characteristics to influence the referral decision. In this study, we used hypothetical case scenarios to assess nephrologists' decisions regarding transplant referral.

Methods

A total of 3180 nephrologists were invited to participate. Among those interested, 252 were randomly selected to receive a survey in which nephrologists were asked whether they would recommend transplant for the 25 hypothetical patients. Logistic regression models with single covariates and multiple covariates were used to identify patient characteristics associated with likelihood of being referred for transplant and to identify nephrologists' characteristics associated with likelihood of referring for transplant.

Results

Of the 252 potential participants, 216 completed the survey. A nephrologist's affiliation with an academic institution was associated with a higher likelihood of referral, and being ‘>10 years from fellowship’ was associated with lower likelihood of referring patients for transplant. Patient age <50 years was associated with higher likelihood of referral. Rural location and smoking history/chronic obstructive pulmonary disease were associated with lower likelihood of being referred for transplant. The nephrologist's affiliation with an academic institution was associated with higher likelihood of referring for preemptive transplant, and the patient having a rural residence was associated with lower likelihood of being referred for preemptive transplant.

Conclusions

The variability in transplant referral is related to patients' age and geographic location as well as the nephrologists' affiliation with an academic institution and time since completion of training. Future educational interventions should emphasize the benefits of kidney transplant and PKT for all population groups regardless of geographic location and age and should target nephrologists in non-academic settings who are 10 or more years from their fellowship training.

Contraindications to kidney transplantation: uneven grounds?

Background

Determining eligibility for a kidney transplant is an important decision. Practice guidelines define contraindications to transplantation; however many are not evidence based. Canadian guidelines recommend that patients unlikely to survive the wait period not be evaluated. The purpose of this study was to evaluate what proportion of patients with a contraindication would survive the wait time.

Methods

Consecutive incident dialysis patients (January 2006 to December 2012) with a contraindication, defined using Canadian guidelines, were studied. Mortality rates were determined for each individual contraindication. Theoretical survival to the median wait time to transplantation was calculated.

Results

Of 746 incident patients, 435 (58 %) were deemed to have a contraindication at dialysis start. Nearly 80 % had a contraindication with a high mortality rate (dementia, multisystem disease, etc.). Patients with high mortality rates were less likely to survive the wait list than be transplanted. Patients with non-adherence, obesity, and potentially reversible disease had relatively low mortality rates, were more likely to survive, and possibly be transplanted at a time with the prospect of a better outcome.

Conclusions

This study gives some credence that many patients with a contraindication are not likely to benefit. A better framework of defining contraindications is needed to allow better decision-making.

Perceived frailty and measured frailty among adults undergoing hemodialysis: a cross-sectional analysis

Background

Frailty, a validated measure of physiologic reserve, predicts adverse health outcomes among adults with end-stage renal disease. Frailty typically is not measured clinically; instead, a surrogate—perceived frailty—is used to inform clinical decision-making. Because correlations between perceived and measured frailty remain unknown, the aim of this study was to assess their relationship.

Methods

146 adults undergoing hemodialysis were recruited from a single dialysis center in Baltimore, Maryland. Patient characteristics associated with perceived (reported by nephrologists, nurse practitioners (NPs), or patients) or measured frailty (using the Fried criteria) were identified using ordered logistic regression. The relationship between perceived and measured frailty was assessed using percent agreement, kappa statistic, Pearson’s correlation coefficient, and prevalence of misclassification of frailty. Patient characteristics associated with misclassification were determined using Fisher’s exact tests, t-tests, or median tests.

Results

Older age (adjusted OR [aOR] = 1.36, 95%CI:1.11-1.68, P = 0.003 per 5-years older) and comorbidity (aOR = 1.49, 95%CI:1.27-1.75, P < 0.001 per additional comorbidity) were associated with greater likelihood of nephrologist-perceived frailty. Being non-African American was associated with greater likelihood of NP- (aOR = 5.51, 95%CI:3.21-9.48, P = 0.003) and patient- (aOR = 4.20, 95%CI:1.61-10.9, P = 0.003) perceived frailty. Percent agreement between perceived and measured frailty was poor (nephrologist, NP, and patient: 64.1%, 67.0%, and 55.5%). Among non-frail participants, 34.4%, 30.0%, and 31.6% were perceived as frail by a nephrologist, NP, or themselves. Older adults (P < 0.001) were more likely to be misclassified as frail by a nephrologist; women (P = 0.04) and non-African Americans (P = 0.02) were more likely to be misclassified by an NP. Neither age, sex, nor race was associated with patient misclassification.

Conclusions

Perceived frailty is an inadequate proxy for measured frailty among patients undergoing hemodialysis.

Perceptions about hemodialysis and transplantation among African American adults with end-stage renal disease: inferences from focus groups

Background

Disparities in access to kidney transplantation (KT) remain inadequately understood and addressed. Detailed descriptions of patient attitudes may provide insight into mechanisms of disparity. The aims of this study were to explore perceptions of dialysis and KT among African American adults undergoing hemodialysis, with particular attention to age- and sex-specific concerns.

Methods

Qualitative data on experiences with hemodialysis and views about KT were collected through four age- and sex-stratified (males <65, males ≥65, females <65, and females ≥65 years) focus group discussions with 36 African American adults recruited from seven urban dialysis centers in Baltimore, Maryland.

Results

Four themes emerged from thematic content analysis: 1) current health and perceptions of dialysis, 2) support while undergoing dialysis, 3) interactions with medical professionals, and 4) concerns about KT. Females and older males tended to be more positive about dialysis experiences. Younger males expressed a lack of support from friends and family. All participants shared feelings of being treated poorly by medical professionals and lacking information about renal disease and treatment options. Common concerns about pursuing KT were increased medication burden, fear of surgery, fear of organ rejection, and older age (among older participants).

Conclusions

These perceptions may contribute to disparities in access to KT, motivating granular studies based on the themes identified.

The role of disparities and socioeconomic factors in access to kidney transplantation and its outcome

BACKGROUND

Research focused on identifying vulnerable populations and revealing specific risk factors for barriers along the pathway from ESRD to kidney transplantation has been mostly descriptive and the causes of existing disparities remain unclear. However, several socio-economic factors that are associated with the access to and the outcome of the kidney transplantation have been identified.

SUMMARY

While the presence of racial, gender, and geographic disparities is noted, we were interested mostly to describe potential socio-economic factors associated with and possibly responsible for the presence of such disparities. In this review we focused on five factors: education level, employment status, income, presence of substance addiction or abuse, and marital status. We describe the new method to quantify patients' socio-economic status and identify the group of high risk in terms of the transplant outcome, easily calculated social adaptability index, previously associated with clinical outcome in several patient populations including those with kidney transplant. At the end, based on literature analyzed we offer potential interventions that potentially can be used in order to reduce the degree of disparities.

CONCLUSION

Based on review of literature socio-economic factors are associated with and possibly responsible for healthcare disparities. Social adaptability index allows quantifying the degree of socio-economic status and identifying the group of high risk for inferior transplant outcome.

A systematic review of the extent and measurement of healthcare provider racism

BACKGROUND

Although considered a key driver of racial disparities in healthcare, relatively little is known about the extent of interpersonal racism perpetrated by healthcare providers, nor is there a good understanding of how best to measure such racism.

OBJECTIVES

This paper reviews worldwide evidence (from 1995 onwards) for racism among healthcare providers; as well as comparing existing measurement approaches to emerging best practice, it focuses on the assessment of interpersonal racism, rather than internalized or systemic/institutional racism.

METHODS

The following databases and electronic journal collections were searched for articles published between 1995 and 2012: Medline, CINAHL, PsycInfo, Sociological Abstracts. Included studies were published empirical studies of any design measuring and/or reporting on healthcare provider racism in the English language. Data on study design and objectives; method of measurement, constructs measured, type of tool; study population and healthcare setting; country and language of study; and study outcomes were extracted from each study.

RESULTS

The 37 studies included in this review were almost solely conducted in the U.S. and with physicians. Statistically significant evidence of racist beliefs, emotions or practices among healthcare providers in relation to minority groups was evident in 26 of these studies. Although a number of measurement approaches were utilized, a limited range of constructs was assessed.

CONCLUSION

Despite burgeoning interest in racism as a contributor to racial disparities in healthcare, we still know little about the extent of healthcare provider racism or how best to measure it. Studies using more sophisticated approaches to assess healthcare provider racism are required to inform interventions aimed at reducing racial disparities in health.

Clinical practice guidelines on wait-listing for kidney transplantation: consistent and equitable?

BACKGROUND

Apparent variability in wait-listing criteria globally has raised concern about inequitable access to kidney transplantation. This study aimed to compare the quality, the scope, and the consistency of international guidelines on wait-listing for kidney transplantation.

METHODS

Electronic databases and guideline registries were searched to December 2011. The Appraisal of Guidelines for Research and Evaluation II instrument and textual synthesis was used to assess and compare recommendations.

RESULTS

Fifteen guidelines published from 2001 to 2011 were included. Methodological rigor and scope were variable. We identified 4 major criteria across guidelines: recipient age and life expectancy, medical criteria, social and lifestyle circumstances, and psychosocial considerations. Whereas some recommendations were consistent, there were differences in age cutoffs, estimated life expectancy (2-5 years), and glomerular filtration rate at listing (15-20 mL/min/1.73 m). Cardiovascular contraindications were broadly defined. Recommended cancer-free periods also varied substantially, and whereas uncontrolled infections were universally contraindicated, human immunodeficiency virus thresholds and adherence to highly active antiretroviral therapy were inconsistent. Most guidelines recommended psychological screening but were not augmented with specific clinical assessment tools.

CONCLUSIONS

Wait-listing recommendations in current guidelines are based on life expectancy, comorbidities, lifestyle, and psychosocial factors. Some recommendations are different across guidelines or broadly defined. There is a case for developing comprehensive, methodologically robust, and regularly updated guidelines on wait-listing for kidney transplantation.

Review of ethnic disparities in access to renal transplantation

Renal transplantation is the gold standard treatment for patients with end-stage renal disease and is associated with several advantages over dialysis, including increased quality of life, reduced morbidity and mortality, and lower healthcare costs. Barring the constraints of a limited organ supply, the goals of the patient care should focus on attaining renal transplantation while minimizing, or even eliminating, time spent on dialysis. Disparities in access to renal transplantation between African Americans and Caucasians have been extensively documented, with African Americans having significantly poorer access. There is a growing corpus of literature examining the determinants of reduced access among other racial ethnic minority groups, including Hispanics. These determinants include patient and physician preference, socioeconomic status, insurance type, patient education, and immunologic factors. We review these determinants in access to renal transplantation in the United States among all races and ethnicities.

Education is associated with reduction in racial disparities in kidney transplant outcome

In this study, we hypothesized that higher level of education might be associated with reduced racial disparities in renal transplantation outcomes. We used data from the United States Renal Data System (September 1, 1990-September 1, 2007) (n=79,223) and analyzed two outcomes, graft loss and recipient mortality, using Cox models. Compared with whites, African Americans had increased risk of graft failure (HR, 1.48; p<0.001) and recipient mortality (HR, 1.06; p=0.004). Compared with recipients who graduated from college, all other education groups had inferior graft survival. Specifically, compared with college-graduated individuals, African Americans who never finished high school had the highest risk of graft failure (HR, 1.45; p<0.001), followed by high school graduates (HR, 1.27; p<0.001) and those with some college education (HR, 1.18; p<0.001). A similar trend was observed in whites. In African Americans (compared with whites), the highest risk of graft failure was associated with individuals who did not complete high school (HR, 1.96; p<0.001) followed by high school graduates (HR, 1.47; p<0.001), individuals with some college education (HR, 1.45; p<0.001), and college graduates (HR, 1.39; p<0.001). A similar trend was observed with recipient mortality. In sum, higher education was associated with reduced racial disparities in graft and recipient survival.

The role of unconscious bias in surgical safety and outcomes

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

Lack of listing status awareness: results of a single-center survey of hemodialysis patients

This study surveyed hemodialysis patients in an urban transplant center serving a predominantly African American population to identify existing and potential barriers to transplantation. The survey used the Dialysis Patient Transplant Questionnaire (DPTQ) to collect self-reported data including interest in a deceased donor kidney transplant and self-reported listing status. We compared patients' survey data to their UNOS listing and computerized medical record at time of interview. Among the 116 patients surveyed, 83 (71.6%) reported interest in a deceased donor kidney transplant. Eighteen (52.9%) of the 34 patients undergoing pretransplantation workup were unaware of their true listing status, and 88.9% of these patients mistakenly believed they were wait listed. All of the patients who mistakenly thought they were listed were undergoing workup. Finding that a significant number of hemodialysis patients who want a deceased donor kidney transplant mistakenly think they are listed when they are not is a documentable deficiency in communication and a potential barrier to transplantation. The finding highlights a correctable problem in communication and work flow that could help to improve transplant center effectiveness. It also reveals that self-reported waiting list status significantly overestimated true waiting list status for our patients at time of interview.

Social Adaptability Index predicts access to kidney transplantation

Identifying the group of subjects prone to disparities in access to kidney transplantation is important for developing potential interventions. Data from the United States Renal Data System (January 1, 1990-September 1, 2007; n = 3407) were used to study association between the Social Adaptability Index (SAI; based upon employment, marital status, education, income, and substance abuse) and outcomes (time to being placed on the waiting list and time to being transplanted once listed). Patients were 56.9 ± 16.1 yr old, 54.2% men, 64.2% white, and 50.4% had diabetes. SAI was higher in whites (7.4 ± 2.4) than African Americans (6.5 ± 2.6) [ANOVA, p < 0.001] and greater in men (7.4 ± 2.4) than in women (6.7 ± 2.5) [T-test, p < 0.001]. In multivariate model, greater SAI (range 0-12) was associated with increased likelihood of being placed on the waiting list (hazard ratio [HR] 1.19 [95% CI 1.15-1.23] per each point of increase in SAI, p < 0.001) and greater likelihood of receiving a transplant once listed (HR of 1.06 [95% CI 1.03-1.09] per point of increase in SAI, p < 0.001). Similar trends were observed in most of the subgroups (based upon race, sex, diabetic status, age, comorbidities, and donor type). SAI is associated with access to renal transplantation in patients with end-stage renal disease; it may be used to indentify individuals at risk of healthcare disparities.

Effect of education on racial disparities in access to kidney transplantation

Higher education level might result in reduced disparities in access to renal transplantation. We analyzed two outcomes: (i) being placed on the waiting list or transplanted without listing and (ii) transplantation in patients who were placed on the waiting list. We identified 3224 adult patients with end-stage renal disease (ESRD) in United States Renal Data System with education information available (mean age of ESRD onset of 57.1 ± 16.2 yr old, 54.3% men, 64.2% white, and 50.4% diabetics). Compared to whites, fewer African Americans graduated from college (10% vs. 16.7%) and a higher percentage never graduated from the high school (38.6% vs. 30.8%). African American race was associated with reduced access to transplantation (hazard ratio [HR] 0.70, p < 0.001 for wait-listing/transplantation without listing; HR 0.58, p < 0.001 for transplantation after listing). African American patients were less likely to be wait-listed/transplanted in the three less-educated groups: HR 0.67 (p = 0.005) for those never completed high school, HR 0.76 (p = 0.02) for high school graduates, and HR 0.65 (p = 0.003) for those with partial college education. However, the difference lost statistical significance in those who completed college education (HR 0.75, p = 0.1). In conclusion, in comparing white and African American candidates, racial disparities in access to kidney transplantation do exist. However, they might be alleviated in highly educated individuals.

Non-medical factors influencing access to renal transplantation

Considering the scarcity of available donor kidneys and the increasing number of patients with end-stage renal disease (ESRD) who would potentially benefit from renal transplantation, objective and equitable patient selection and equitable access to renal transplantation bear substantial importance. Inequalities in access to renal transplantation have been extensively documented over the last 2 decades with regard to age, gender, ethnicity, socioeconomic and psycho-social factors. In this paper we review a wide spectrum of social, patient and system-related factors along the transplantation process that may be associated with disparities, and we aim to describe the complex interrelationship between these factors that might influence treatment decisions by patients and health-care professionals. Understanding potentially modifiable barriers to kidney transplantation may allow designing targeted interventions in order to guarantee fair recipient selection and equal access to renal transplantation.

Neighborhood poverty and kidney transplantation among US Asians and Pacific Islanders with end-stage renal disease

The degree to which low transplant rates among Asians and Pacific Islanders in the United States are confounded by poverty and reduced access to care is unknown. We examined the relationship between neighborhood poverty and kidney transplant rates among 22 152 patients initiating dialysis during 1995-2003 within 1800 ZIP codes in California, Hawaii and the US-Pacific Islands. Asians and whites on dialysis were distributed across the spectrum of poverty, while Pacific Islanders were clustered in the poorest areas. Overall, worsening neighborhood poverty was associated with lower relative rates of transplant (adjusted HR [95% CI] for areas with > or =20% vs. <5% residents living in poverty, 0.41 [0.32-0.53], p < 0.001). At every level of poverty, Asians and Pacific Islanders experienced lower transplant rates compared with whites. The degree of disparity increased with worsening neighborhood poverty (adjusted HR [95% CI] for Asians-Pacific Islanders vs. whites, 0.64 [0.51-0.80], p < 0.001 for areas with <5% and 0.30 [0.21-0.44], p < 0.001 for areas with > or =20% residents living in poverty; race-poverty level interaction, p = 0.039). High levels of neighborhood poverty are associated with lower transplant rates among Asians and Pacific Islanders compared with whites. Our findings call for studies to identify cultural and local barriers to transplant among Asians and Pacific Islanders, particularly those residing in resource-poor neighborhoods.

Are physician estimates of asthma severity less accurate in black than in white patients?

BACKGROUND

Racial differences in asthma care are not fully explained by socioeconomic status, care access, and insurance status. Appropriate care requires accurate physician estimates of severity. It is unknown if accuracy of physician estimates differs between black and white patients, and how this relates to asthma care disparities.

OBJECTIVE

We hypothesized that: 1) physician underestimation of asthma severity is more frequent among black patients; 2) among black patients, physician underestimation of severity is associated with poorer quality asthma care.

DESIGN, SETTING AND PATIENTS

We conducted a cross-sectional survey among adult patients with asthma cared for in 15 managed care organizations in the United States. We collected physicians' estimates of their patients' asthma severity. Physicians' estimates of patients' asthma as being less severe than patient-reported symptoms were classified as underestimates of severity.

MEASUREMENTS

Frequency of underestimation, asthma care, and communication.

RESULTS

Three thousand four hundred and ninety-four patients participated (13% were black). Blacks were significantly more likely than white patients to have their asthma severity underestimated (OR = 1.39, 95% CI 1.08-1.79). Among black patients, underestimation was associated with less use of daily inhaled corticosteroids (13% vs 20%, p < .05), less physician instruction on management of asthma flare-ups (33% vs 41%, p < .0001), and lower ratings of asthma care (p = .01) and physician communication (p = .04).

CONCLUSIONS

Biased estimates of asthma severity may contribute to racially disparate asthma care. Interventions to improve physicians' assessments of asthma severity and patient-physician communication may minimize racial disparities in asthma care.

Gender differences across race/ethnicity in use of health care among Medicare-aged Americans

BACKGROUND

Despite Medicare, medical services are not equally used by elderly women and men in the United States. Our purpose is to examine gender differences in healthcare utilization among older Americans, the persistence of gender differences across race/ethnicity, and the roles of sociodemographic, health, and economic factors to explain differences.

METHODS

Data from the 1998-2000 Health and Retirement Study are used to investigate gender differences in use of hospital, outpatient surgery, home health, and physician services. Analyses are controlled for sociodemographic, health (medical conditions, functional health), and economic (income, wealth, education, health insurance) factors.

RESULTS

Women are significantly less likely to use hospital service (odds ratio [OR]=0.83) and outpatient surgery (OR=0.85) but are more likely to use home health care (OR=1.27) and physician services (OR=1.45), controlling for sociodemographics. Differences in health needs and economic resources partially mediate the gender differences in physician and home healthcare utilization but do not explain the gender differences in hospital service and outpatient surgery. Notably, African American, Hispanic, and white women compared with men show significantly less use of hospital services.

CONCLUSIONS

Gender differences in medical use vary according to the type of services used and are largely consistent across racial/ethnic groups. As the size of the Medicare population increases, promoting equitable use of healthcare resources by both women and men is an important issue in developing healthcare policy and designing public health strategies.

Predictors of patient selection in bariatric surgery

OBJECTIVE

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

SUMMARY BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Compliance with American Academy of Pediatrics and American Public Health Association illness exclusion guidelines for child care centers in Maryland: who follows them and when?

BACKGROUND

In 1992, the American Academy of Pediatrics and the American Public Health Association jointly published guidelines for temporary exclusion of sick children from child care. However, little is known about key stakeholders' compliance with these guidelines.

OBJECTIVES

The purpose of this work was to compare pediatricians', parents', and child care providers' compliance with American Academy of Pediatrics guidelines and determine predictors for higher rates of compliance.

METHODS

We conducted a cross-sectional survey of 215 randomly selected Maryland pediatricians, 223 parents, and 192 child care providers from 22 Baltimore, Maryland, child care centers from January to July 2004. Questionnaires contained the following 6 case vignettes depicting common child care illnesses: upper respiratory infection, conjunctivitis, gastroenteritis, mild febrile illness, tinea capitis, and atopic dermatitis. The instrument measured the correctness of exclusion and inclusion decisions (using American Academy of Pediatrics/American Public Health Association guidelines as gold standard) according to varying levels of fever, disease severity (eg, clear versus yellow eye discharge), familiarity with the child, and parent work schedule flexibility.

RESULTS

Response rates were 71% for pediatricians, 56% for parents, and 85% for child care providers. Guideline compliance was higher for pediatricians (74%) than for child care providers (60%) and parents (61%). Only 23% of pediatricians and parents and 29% of child care providers reported familiarity with American Academy of Pediatrics/American Public Health Association guidelines by name. In general, child care providers and parents had lower false-negative rates (allowed fewer children to attend who met criteria for exclusion) than pediatricians, suggesting that pediatricians may underexclude. Child care providers and parents correctly excluded in 65%-98% of cases requiring exclusion, whereas pediatricians correctly excluded 31%-86% of cases requiring exclusion, depending on the vignette. Yet pediatricians were much more specific about which children met criteria (pediatricians correctly included 61%-93% of cases requiring inclusion versus child care providers and parents who correctly included 20%-75% of such cases), suggesting that child care providers and parents may overexclude. Compliance rates varied significantly by stakeholder, vignette (disease), level of fever, and disease severity but did not vary with the stakeholder's familiarity with the child or the flexibility of the parent's work schedule.

CONCLUSIONS

Pediatricians, parents, and child care providers were unfamiliar with American Academy of Pediatrics/American Public Health Association illness exclusion guidelines by name but moderately compliant with them. When noncompliant, child care providers and parents generally overexcluded, and pediatricians underexcluded. Stakeholder- and disease-specific predictors for noncompliance gleaned from this study suggest how educational interventions aiming to increase guideline compliance could be individually tailored to child care providers, parents, and pediatricians.

New insights into the epidemiology of chronic kidney disease in US Asians and Pacific Islanders

PURPOSE OF REVIEW

In contrast to advances in our understanding of health disparities in other ethnic groups within the US, differential outcomes associated with chronic kidney disease among US Asians have gone largely unexamined. Until recently, risk estimates for chronic kidney disease outcomes among US Pacific Islanders were virtually unknown. This review highlights recent contributions to our understanding of chronic kidney disease outcomes in US Asians and Pacific Islanders.

RECENT FINDINGS

Asians in the US appear to have a higher risk of end-stage renal disease relative to US whites after accounting for baseline kidney disease and many of the known risk factors for end-stage renal disease. The origins of the discrepancy in risk for end-stage renal disease between US Asians and whites do not appear to be explained by the socioeconomic and comorbidity disparities paradigm present in the US black vs. white model. Mounting evidence suggests that US Asians and Pacific Islanders receive substantially less predialysis care and proportionally fewer kidney transplants compared with US whites. Paradoxically, these populations have equivalent or better survival on dialysis.

SUMMARY

These data highlight the need for studies to elucidate the mechanisms underlying the differential outcomes observed among US Asians and Pacific Islanders. Efforts to identify ethnicity-specific risk factors for kidney disease and interventions aimed at promoting predialysis care and kidney transplantation among US Asians and Pacific Islanders could substantially reduce morbidity, mortality, and costs.

Differential mortality and transplantation rates among Asians and Pacific Islanders with ESRD

Few studies in patients with ESRD have examined outcomes in Asian or Pacific Islander subgroups compared with white individuals. The objective of this study was to assess ethnic disparities in mortality and kidney transplantation among a multiethnic cohort of incident dialysis patients. A total of 24,963 patients who initiated dialysis within the TransPacific Renal Network (Network 17) between April 1, 1995, and September 30, 2001, were studied to ascertain death and kidney transplantation through September 30, 2002. Overall, 12,902 deaths and 2258 kidney transplantations were observed during 59,075 person-years of follow-up. Mortality on dialysis among Asians and Pacific Islanders (except Chamorros) was lower than that of white individuals after controlling for differences in sociodemographic characteristics, comorbid conditions, and other risk factors for death (adjusted hazard ratio [95% confidence interval] versus white individuals: Japanese 0.64 [0.57 to 0.72], Chinese 0.64 [0.52 to 0.78], Filipino 0.64 [0.57 to 0.72], Native Hawaiian 0.84 [0.72 to 0.96], Samoan 0.62 [0.48 to 0.82], and Chamorro 0.96 [0.84 to 1.20]). In contrast, Asians and Pacific Islanders were much less likely to undergo kidney transplantation (adjusted rate ratio [95% confidence interval] versus white individuals: Japanese 0.34 [0.24 to 0.46], Chinese 0.54 [0.30 to 0.88], Filipino 0.32 [0.26 to 0.47], Native Hawaiian 0.17 [0.10 to 0.30], Samoan 0.17 [0.07 to 0.38], and Chamorro 0.04 [0.01 to 0.14]). Despite wide variations in primary cause of ESRD, clinical characteristics, and body size at dialysis initiation, Asians and Pacific Islanders experience better survival but substantially lower transplantation rates compared with white individuals. Strategies that are aimed at improving access to transplantation in Asian and Pacific Islander communities may further enhance survival among Asians and Pacific Islanders with ESRD.

Health disparities in transplantation: focus on the complexity and challenge of renal transplantation in African Americans

The field of renal transplantation has grown exponentially as a result of a greater understanding of the immune system and the advent of numerous immunosuppressive agents. Although African Americans and whites have benefited from these advances, equivalent long-term success eludes African Americans who are disadvantaged in gaining access to renal transplantation. This review summarizes the obstacles for African Americans to end-stage renal disease(ESRD) care, focusing on transplantation. Factors that predispose African Americans for ESRD, impede this ethnic group from timely transplantation, and negatively influence graft survival are examined. Possible solutions to these persistent problems are offered.

Racial disparities in hospitalized elderly patients with chronic heart failure

The purpose of this study was to examine the impact of race on length of hospital stay (LOS) and number of procedures on elderly persons hospitalized with chronic heart failure (CHF). Secondary data analysis was used to obtain data on 99,543 hospitalized Medicare patients with CHF age 65 years or older. MANOVA was utilized to examine the effects of race, age, and total hospital charges on LOS, number of procedures, and diagnosis. Asian American Pacific Islanders had significantly higher number of procedures and LOS compared to Whites. The combined dependent variables were significantly affected by race, F(9, 99,543) = 121.95, p =.000; the covariates of age, F(3, 99,543) = 720.65, p =.000; and total charges F(3, 99,543) = 38,962.95, p =.000. LOS accounted for 50% of the variance. Studies that examine cultural variables and their effect on LOS and number of procedures are needed.

The impact of international medical graduate status on primary care physicians' choice of specialist

BACKGROUND

Approximately one fourth of practicing physicians in the United States graduated from medical schools in other countries. It is unknown how the role of international medical graduate status affects physician decision-making.

OBJECTIVE

The objective of this study was to determine whether a primary care physicians' knowledge of a specialist's international medical graduate status affects his or her decision to refer patients to that specialist.

RESEARCH DESIGN AND SUBJECTS

We studied a national, cross-sectional study of primary care physicians who see adult patients. The sample was drawn from the American Medical Association Physician's Professional Data. Each physician received 2 clinical case vignettes describing a patient for whom referral to a specialist was considered necessary. Each vignette was followed by 5 vignette specialist descriptions with medical school graduate status varied randomly alongside other physician characteristics.

MEASURE

We measured the decision to refer to an international versus U.S. medical graduate specialist.

RESULTS

Of 1054 eligible physicians, 623 (59.1%) responded. Respondents were significantly more likely to refer to a U.S. medical graduate (USMG) compared with an international medical graduate (IMG) (63% vs. 54%, P <0.05). After adjustment for age, race, sex, and referral characteristics of the vignette specialists, a positive referral decision was noted in a higher proportion of vignettes in which the vignette specialist was described as a USMG versus an IMG (63% vs. 51%, P <0.05).

CONCLUSION

With other factors being equal, vignette specialists described as IMGs versus USMGs were significantly less likely to be associated with a positive referral decision. Although specialist IMG status, relative to other factors, might not have a major effect on referral decisions, it is possible that negative views of international medical graduates could lead to suboptimal choices in referral decisions. Potentially, a patient could be referred to an USMG who happens to have inferior clinical skills than an IMG with superior clinical skills.

Physicians' beliefs about racial differences in referral for renal transplantation

BACKGROUND

Black patients with end-stage renal disease are much less likely than white patients to undergo renal transplantation, but previous research has shown that black patients are only slightly less likely to desire this procedure. A better understanding of physicians' views about racial differences in access to transplantation may help reduce disparities in care.

METHODS

We surveyed 278 nephrologists in 4 US regions about quality of life and survival for black and white patients undergoing renal transplantation and reasons for racial differences in access to transplantation. We also surveyed 606 of their patients about their care.

RESULTS

Physicians were less likely to believe transplantation improves survival for blacks than whites (69% versus 81%; P = 0.001), but similarly likely to believe it improves quality of life (84% versus 86%). Factors commonly cited by physicians as important reasons why blacks are less likely than whites to be evaluated for transplantation included patients' preferences (66%), availability of living donors (66%), failure to complete evaluations (53%), and comorbid illnesses (52%). Fewer physicians perceived patient-physician communication and trust (38%) or physician bias (12%) as important reasons. Black patients were less likely than white patients to report receiving some or a lot of information about transplantation (55% versus 74%; P = 0.006) when their physicians did not view patient-physician communication and trust as an important reason for racial differences in care.

CONCLUSION

Nephrologists' views about the benefits of renal transplantation and reasons for racial differences in access to this procedure may affect how they present this treatment option to black and white patients.

Impact of nephrology referral on early and midterm outcomes in ESRD: EPidémiologie de l'Insuffisance REnale chronique terminale en Lorraine (EPIREL): results of a 2-year, prospective, community-based study

BACKGROUND

Most studies looking at how the outcome of end-stage renal disease (ESRD) is affected by the timing and quality of the care received before initiation of renal replacement therapy (RRT) are inconclusive.

METHODS

Five hundred and two adult French patients (age, 62.8 +/- 16 years) receiving their first RRT were enrolled in a 2-year, community-based, prospective study. Subjects were assigned to 1 of 5 groups depending on the time between their first serum creatinine reading above 2 mg/dL (177 micromol/L): chronic renal failure (CRF) and nephrology referral (NR) and RRT. Multivariate logistic regression was used to analyze 90-day survival data, and data concerning long-term survival and inclusion on the waiting list for renal transplantation were analyzed using Cox proportional hazards regression.

RESULTS

Overall survival rates were 88% at 90 days, 77.2% at 1 year, 65.2% at 2 years, and 54.2% at 3 years. The nephrology referral pattern was associated with age and systolic blood pressure, and independently predicted early death. Compared with group 1 (NR > 12 months), odds ratios (confidence interval 95%) were 2.7 (1.2 to 6.3) for group 2 (NR < or = 12 months or >4 months), 2.8 (1.0 to 8.0) for group 3 (NR < or = 4 months or >1 month), 4.9 (2.2 to 11.0) for group 4 (NR < or = 1 month; CRF > 1 month), and 5.2 (2.2 to 12.3) for group 5 (NR < or = 1 month; CRF < or = 1 month). Independent predictors of death in 90-day survivors were age, cardiac disease with previous episodes of heart failure, vascular disease, low diastolic blood pressure, and group 3 referral pattern. Not being entered on the waiting list for renal transplantation was predicted by age, diabetes, vascular disease, and nonelective first dialysis.

CONCLUSION

Late nephrology referral is strongly associated with early death. Emergency first dialysis is an independent risk factor for not being placed on the waiting list for transplantation. Among 90-day survivors, referral pattern has little influence on mortality, which is mainly determined by cardiovascular complications at initiation of RRT.

Renal transplantation for Indigenous Australians: identifying the barriers to equitable access

OBJECTIVE

To assess Indigenous Australians' access to renal transplantation, compared with non-Indigenous Australians. To examine whether disparities are due to a lower rate of acceptance onto the waiting list and/or a lower rate of moving from the list to transplantation.

DESIGN

National cohort study using data from the Australian and New Zealand Dialysis and Transplant Registry. We included all end-stage renal disease (ESRD) patients under 65 years of age who started treatment in Australia between January 1993 and December 1998. We used survival analysis to examine the time from commencement of renal replacement therapy (RRT) to transplantation. We measured time from commencement of RRT to acceptance onto the waiting list (stage 1), and time from acceptance onto the waiting list to transplantation (stage 2). The main outcome measures were (1) acceptance onto the waiting list and (2) receipt of a transplant, before 31 March 2000.

RESULTS

Indigenous patients had a lower transplantation rate (adjusted Indigenous: non-Indigenous rate ratio 0.32, 95% CI 0.25-0.40). They had both a lower rate of acceptance onto the waiting list (adjusted rate ratio 0.50, 95% CI 0.44-0.57) and a lower rate of moving from the list to transplantation (adjusted rate ratio 0.50, 95% CI 0.38-0.65). The disparities were not explained by differences in age, sex, co-morbidities or cause of renal disease.

CONCLUSIONS

Indigenous Australians face barriers to acceptance onto the waiting list and to moving from the list to transplantation. Further research to identify the causes could facilitate strategies to improve equity in transplantation.

Paved with good intentions: do public health and human service providers contribute to racial/ethnic disparities in health?

There is extensive evidence of racial/ethnic disparities in receipt of health care. The potential contribution of provider behavior to such disparities has remained largely unexplored. Do health and human service providers behave in ways that contribute to systematic inequities in care and outcomes? If so, why does this occur? The authors build on existing evidence to provide an integrated, coherent, and sound approach to research on providers' contributions to racial/ethnic disparities. They review the evidence regarding provider contributions to disparities in outcomes and describe a causal model representing an integrated set of hypothesized mechanisms through which health care providers' behaviors may contribute to these disparities.

Psychosocial issues in women with renal disease

In this article, we review data on the epidemiology and outcomes of women in the US End-Stage Renal Disease (ESRD) Program. The complexity of the psychosocial milieu of patients is described, and levels of analysis are delineated. The relationships between age, marital status and satisfaction, and perception of quality of life and depressive affect level and diagnosis of depression, and medical outcomes have not been determined in large studies of women with renal disease. We present data from our cross-sectional and longitudinal studies of psychosocial outcomes in a population comprised primarily of black patients with ESRD and review some differences between relationships of parameters in the groups of men and women in the study. Women are more likely to be kidney donors rather than recipients in national programs. Women with ESRD treated with hemodialysis appear to be more immunologically responsive to the psychosocial milieu than men. These differences in access to and utilization of health care and relationships between perceptions and immunochemical mediators may have important ramifications for outcomes in women with chronic renal disease.