Geographic inequity in transplant access

Ethical and Policy Issues Arising in Crowdfunding for Solid Organ Transplantation: A Content Analysis of Newspaper Coverage of Recipient and Donor Fundraising Campaigns

BACKGROUND

Solid organ transplantation improves the quality of life for patients but has significant out-of-pocket expenses for donors and recipients in the USA, leading many to utilize crowdfunding for donations to cover expenses. We sought to characterize crowdfunding for transplant patients and to identify ethical and policy issues.

METHODS

We obtained newspaper articles that described crowdfunding campaigns for organ transplant patients from Nexis-Uni. Using Nvivo, we identified and analyzed article details, patient characteristics, features of campaigns, additional fundraisers, and policy and ethical issues related to crowdfunding.

RESULTS

Most sources were published between 2015 and 2020. Of 231 patients identified, 43% were thoracic organ recipients and 42% were kidney recipients. GoFundMe was the most popular platform. 78% of patients reported at least one intended use of crowdfunding; medical expenses were the most cited reason. Ten percent of articles described at least one ethical or policy consideration related to crowdfunding for organ transplant. Concerns included violations of federal laws prohibiting donors from receiving "valuable consideration" for an organ, taxation of funds, loss of Medicaid or disability benefits, accountability for fund usage, and crowdfunding requirements for organ waiting list placement. In several cases, transplants were delayed due to crowdfunding concerns.

CONCLUSIONS

Our findings reveal crowdfunding characteristics and financial barriers present among transplant patients. Furthermore, our study suggests that the ethical and policy implications for crowdfunding in the transplant population are not yet adequately assessed. National regulations and transplant center policies may need to be modified to address issues raised by patient crowdfunding.

Liver transplantation access and outcomes: Impact of variations in liver-specific specialty care

BACKGROUND

We sought to characterize the impact access to gastroenterologists/hepatologists has on liver transplantation listing, as well as time on the liver transplantation waitlist and post-transplant outcomes.

METHODS

Liver transplantation registrants aged >18 years between January 1, 2004 and December 31, 2019 were identified from the Scientific Registry of Transplant Recipients Standard Analytic Files. The liver transplantation registration ratio was defined as the ratio of liver transplant waitlist registrations in a given county per 1,000 liver-related deaths.

RESULTS

A total of 150,679 liver transplantation registrants were included. Access to liver transplantation centers and liver-specific specialty physicians varied markedly throughout the United States. Of note, the liver transplantation registration ratio was lower in counties with poor access to liver-specific care versus counties with adequate access (poor access 137.2, interquartile range 117.8-163.2 vs adequate access 157.6, interquartile range 127.3-192.2, P < .001). Among patients referred for liver transplantation, the cumulative incidence of waitlist mortality and post-transplant graft survival was comparable among patients with poor versus adequate access to liver-specific care (both P > .05). Among liver transplantation recipients living in areas with poor access, after controlling for recipient and donor characteristics, cold ischemic time, and model for end-stage liver disease score, the area deprivation index predicted graft survival (referent, low area deprivation index; medium area deprivation index, hazard ratio 1.52, 95% confidence interval 1.03-12.23; high area deprivation index, 1.45, 95% confidence interval 1.01-12.09, both P < .05).

CONCLUSION

Poor access to liver-specific care was associated with a reduction in liver transplantation registration, and individuals residing in counties with high social deprivation had worse graft survival among patients living in counties with poor access to liver-specific care.

Equity in Transplantation Access in Nepal: An Analysis of Gender, Geographic, and Caste-Based Disparities in Transplants

Transplantation is a lifesaving modality for addressing various organ failures. While kidney transplant services became available in Nepal in 2008, the introduction of liver transplantation is more recent. The government provides financial assistance to support lifelong dialysis and kidney transplantation. The importance of equitable access to transplantation cannot be overemphasized. This study aims to examine the equity in accessing transplantation services. This retrospective observational study encompasses patients who underwent kidney transplantation up until December 2022 across five major hospitals. Through standardized data collection and analysis, we evaluated the distribution of recipients based on gender, caste/ethnicity, and geographic location. A total of 2040 kidney transplantations were performed during the period. Notably, 79% of the recipients were men and, interestingly, 70% of the donors were women. Geographically, the highest proportion (31.8%) of recipients were from Bagmati, while the lowest (l2.8%) were from Karnali. Regarding caste and ethnicity, Janajatis accounted for 31% and Chhetris for 22.9%; Madhesis were lowest at 8.12%. Only 17 liver transplantations were conducted during the same period. Although access to kidney transplantation exists in Nepal, this study highlights persistent disparities. Women, rural and remote populations, as well as specific ethnic and caste groups encounter barriers to accessing transplantation services.

Geographic hot spots of kidney transplant candidates wait-listed post-dialysis

INTRODUCTION

Preemptive wait-listing of deceased donor kidney transplant (DDKT) candidates before maintenance dialysis increases the likelihood of transplantation and improves outcomes among transplant patients. Previous studies have identified substantial disparities in rates of preemptive listing, but a gap exists in examining geographic sources of disparities, particularly for sub-regional units. Identifying small area hot spots where delayed listing is particularly prevalent may more effectively inform both health policy and regionally appropriate interventions.

METHODS

We conducted a retrospective cohort study utilizing 2010-2020 Scientific Registry of Transplant Recipients (SRTR) data for all DDKT candidates to examine overall and race-stratified geospatial hot spots of post-dialysis wait-listing in U.S. zip code tabulation areas (ZCTA). Three geographic clustering methods were utilized to identify robust statistically significant hot spots of post-dialysis wait-listing.

RESULTS

Novel sub-regional hot spots were identified in the southeast, southwest, Appalachia, and California, with a majority existing in the southeast. Race-stratified results were more nuanced, but broadly reflected similar patterns. Comparing transplant candidates in hot spots to candidates in non-clusters indicated a strong association between residence in hot spots and high area deprivation (OR: 6.76, 95%CI: 6.52-7.02), indicating that improving access healthcare in these areas may be particularly beneficial.

CONCLUSION

Our study identified overall and race-stratified hot spots with low rates of preemptive wait list placement in the U.S., which may be useful for prospective healthcare policy and interventions via targeting of these narrowly defined geographical areas.

County-level Differences in Liver-related Mortality, Waitlisting, and Liver Transplantation in the United States

BACKGROUND

Much of our understanding regarding geographic issues in transplantation is based on statistical techniques that do not formally account for geography and is based on obsolete boundaries such as donation service area.

METHODS

We applied spatial epidemiological techniques to analyze liver-related mortality and access to liver transplant services at the county level using data from the Centers for Disease Control and Prevention and Scientific Registry of Transplant Recipients from 2010 to 2018.

RESULTS

There was a significant negative spatial correlation between transplant rates and liver-related mortality at the county level (Moran's I, -0.319; P  = 0.001). Significant clusters were identified with high transplant rates and low liver-related mortality. Counties in geographic clusters with high ratios of liver transplants to liver-related deaths had more liver transplant centers within 150 nautical miles (6.7 versus 3.6 centers; P  < 0.001) compared with all other counties, as did counties in geographic clusters with high ratios of waitlist additions to liver-related deaths (8.5 versus 2.5 centers; P  < 0.001). The spatial correlation between waitlist mortality and overall liver-related mortality was positive (Moran's I, 0.060; P  = 0.001) but weaker. Several areas with high waitlist mortality had some of the lowest overall liver-related mortality in the country.

CONCLUSIONS

These data suggest that high waitlist mortality and allocation model for end-stage liver disease do not necessarily correlate with decreased access to transplant, whereas local transplant center density is associated with better access to waitlisting and transplant.

The Scope of Telemedicine in Kidney Transplantation: Access and Outreach Services

Access to transplant centers is a key barrier for kidney transplant evaluation and follow-up care for both the recipient and donor. Potential kidney transplant recipients and living kidney donors may face geographic, financial, and logistical challenges in engaging with a transplant center and maintaining post-transplant continuity of care. Telemedicine via synchronous video visits has the potential to overcome the access barrier to transplant centers. Transplant centers can start the evaluation process for potential recipients and donors via telemedicine, especially for those who have challenges to come for an in-person visit or when there are restrictions on clinic capacities, such as during a pandemic. Similarly, transplant centers can use telemedicine to sustain post-transplant follow-up care while avoiding the burden of travel and its associated costs. However, expansion to telemedicine-based kidney transplant services is substantially dependent on telemedicine infrastructure, insurer policy, and state regulations. In this review, we discuss the practice of telemedicine in kidney transplantation and its implications for expanding access to kidney transplant services and outreach from pretransplant evaluation to post-transplant follow-up care for the recipient and donor.

Impact of Social Vulnerability on Access to Educational Programming Designed to Enhance Living Donation

INTRODUCTION

Transplant candidate participation in the Living Donor Navigator Program is associated with an increased likelihood of achieving living donor kidney transplantation; yet not every transplant candidate participates in navigator programming.

RESEARCH QUESTION

We sought to assess interest and ability to participate in the Living Donor Navigator Program by the degree of social vulnerability.

DESIGN

Eighty-two adult kidney-only candidates initiating evaluation at our center provided Likert-scaled responses to survey questions on interest and ability to participate in the Living Donor Navigator Program. Surveys were linked at the participant-level to the Centers for Disease Control and Prevention Social Vulnerability Index and county health rankings and overall social vulnerability and subthemes, individual barriers, telehealth capabilities/ knowledge, interest, and ability to participate were assessed utilizing nonparametric Wilcoxon ranks sums tests, chi-square, and Fisher's exact tests.

RESULTS

Participants indicating distance as a barrier to participation in navigator programming lived approximately 82 miles farther from our center. Disinterested participants lived in areas with the highest social vulnerability, higher physical inactivity rates, lower college education rates, and higher uninsurance (lack of insurance) and unemployment rates. Similarly, participants without a computer, who never heard of telehealth, and who were not encouraged to participate in telehealth resided in areas of highest social vulnerability.

CONCLUSION

These data suggest geography combined with being from under-resourced areas with high social vulnerability was negatively associated with health care engagement. Geography and poverty may be surrogates for lower health literacy and fewer health care interactions.

Limitations of current liver donor allocation systems and the impact of newer indications for liver transplantation

Liver transplantation represents a life-saving treatment for patients with decompensated cirrhosis, a severe condition associated with a high risk of waiting list mortality. When decompensation occurs rapidly in the presence of extrahepatic organ failures, the condition is called acute-on-chronic liver failure, which is associated with an even higher risk of death, though liver transplantation can also markedly improve survival in affected patients. However, there are still gaps in our understanding of how to optimise prioritisation and organ allocation, as well as survival among patients with acute-on-chronic liver failure (both before and after transplant). Moreover, it is urgent to address inequalities in access to liver transplantation in patients with severe alcoholic hepatitis and non-alcoholic steatohepatitis. Several controversies still exist regarding gender and regional disparities, as well as the use of suboptimal donor grafts. In this review, we aim to provide a critical perspective on the role of liver transplantation in patients with decompensated cirrhosis and address areas of ongoing uncertainty.

Association of High Burden of End-stage Kidney Disease With Decreased Kidney Transplant Rates With the Updated US Kidney Allocation Policy

Importance

The Organ Procurement and Transplantation Network (OPTN) approved changes to the US kidney allocation system in 2019. The potential effects of this policy change using transplant rates normalized to end-stage kidney disease (ESKD) incidence have not been investigated.

Objective

To estimate how the OPTN kidney allocation policy will affect areas of the US currently demonstrating low rates of kidney transplant, when accounting for the regional burden of ESKD.

Design, Setting, and Participants

This cross-sectional population-based economic evaluation analyzed access of patients with ESKD to kidney transplant in the US. Participants included patients with incident ESKD, those on the kidney transplant wait list, and those who received a kidney transplant. Data were collected from January 1 to December 31, 2017, and were analyzed in 2019.

Main Outcomes and Measures

The probability of a patient with ESKD being placed on the transplant wait list or receiving a deceased donor kidney transplant. States and donor service areas (DSAs) were compared for gains and losses in rates of transplanted kidneys under the new allocation system. Transplant rates were normalized for ESKD burden.

Results

A total of 122 659 patients had incident ESKD in the US in 2017 (58.2% men; mean [SD] age, 62.8 [15.1] years). The probability of a patient with ESKD receiving a deceased donor kidney transplant varied 3-fold across the US (from 6.36% in West Virginia to 18.68% in the District of Columbia). Modeling of the OPTN demonstrates that DSAs from New York (124%), Georgia (65%), and Illinois (56%) are estimated to experience the largest increases in deceased donor kidney allocation. Other than Georgia, these states have kidney transplant rates per incident ESKD cases above the mean (of 50 states plus the District of Columbia, New York is 16th and Illinois is 24th). In contrast, DSAs from Nevada (-74%), Ohio (-67%), and North Carolina (-61%)-each of which has a transplant rate per incident ESKD cases significantly below the mean-are estimated to experience the largest decreases in deceased donor allocation (of 50 states plus the District of Columbia, North Carolina is 34th, Ohio is 38th, and Nevada is 47th).

Conclusions and Relevance

The new OPTN-approved kidney allocation policy may result in worsening geographic disparities in access to transplants when measured against the burden of ESKD within a particular region of the US.

Evaluating Spatial Associations in Inpatient Deaths Between Organ Procurement Organizations

To improve the measurement of organ procurement organization (OPO) performance, the Center for Medicare and Medicaid Services recently proposed using inpatient deaths defined as the eligible pool of organ donors within an OPO as patients 75 years or younger that died from any cause that would not preclude donation.

METHODS

To account for the geographic variation in OPO performance and organ availability across the United States, we utilized spatial analysis to appraise the newly proposed metric of inpatient deaths.

RESULTS

Using spatial clustering that accounts for geographic relationships between Organ Procurement Organizations, the top 5 causes of donation-eligible death, and inpatient deaths, we identified 4 unique OPO clusters. Each group had a distinct demographic composition, cause of death, and inpatient death pattern. In multivariate analysis accounting for these geographic relationships, the spatial clusters remained significantly associated with the outcome of inpatient deaths (P < 0.001) and were the best-fitting model compared with models without the spatial clusters; this suggests that further risk adjustment of inpatient deaths should include these geographic considerations.

CONCLUSIONS

This approach provides not only a manner to assess donor potential by improving risk adjustment but also an opportunity to further explore geographic and spatial relationships in the practice of organ transplantation and OPO performance.

Endpoints and design of clinical trials in patients with decompensated cirrhosis: Position paper of the LiverHope Consortium

Management of decompensated cirrhosis is currently geared towards the treatment of complications once they occur. To date there is no established disease-modifying therapy aimed at halting progression of the disease and preventing the development of complications in patients with decompensated cirrhosis. The design of clinical trials to investigate new therapies for patients with decompensated cirrhosis is complex. The population of patients with decompensated cirrhosis is heterogeneous (i.e., different etiologies, comorbidities and disease severity), leading to the inclusion of diverse populations in clinical trials. In addition, primary endpoints selected for trials that include patients with decompensated cirrhosis are not homogeneous and at times may not be appropriate. This leads to difficulties in comparing results obtained from different trials. Against this background, the LiverHope Consortium organized a meeting of experts, the goal of which was to develop recommendations for the design of clinical trials and to define appropriate endpoints, both for trials aimed at modifying the natural history and preventing progression of decompensated cirrhosis, as well as for trials aimed at managing the individual complications of cirrhosis.

Kidney transplant program waitlisting rate as a metric to assess transplant access

Kidney transplant program performance in the United States is commonly measured by posttransplant outcomes. Inclusion of pretransplant measures could provide a more comprehensive assessment of transplant program performance and necessary information for patient decision-making. In this study, we propose a new metric, the waitlisting rate, defined as the ratio of patients who are waitlisted in a center relative to the person-years referred for evaluation to a program. Furthermore, we standardize the waitlisting rate relative to the state average in Georgia, North Carolina, and South Carolina. The new metric was used as a proof-of-concept to assess transplant-program access compared to the existing transplant rate metric. The study cohorts were defined by linking 2017 United States Renal Data System (USRDS) data with transplant-program referral data from the Southeastern United States between January 1, 2012 and December 31, 2016. Waitlisting rate varied across the 9 Southeastern transplant programs, ranging from 10 to 22 events per 100 patient-years, whereas the program-specific waitlisting rate ratio ranged between 0.76 and 1.33. Program-specific waitlisting rate ratio was uncorrelated with the transplant rate ratio (r = -.15, 95% CI, -0.83 to 0.57). Findings warrant collection of national data on early transplant steps, such as referral, for a more comprehensive assessment of transplant program performance and pretransplant access.