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Green SM, Spaulding AC, Brennan ER, Jarmi T. Comparison Between Black Non-Hispanic and White Non-Hispanic Simultaneous Pancreas-Kidney Transplant Candidates and Recipients. Clin Transplant 2024; 38:e15392. [PMID: 38967601 DOI: 10.1111/ctr.15392] [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: 01/26/2024] [Revised: 05/14/2024] [Accepted: 06/13/2024] [Indexed: 07/06/2024]
Abstract
INTRODUCTION This study examined simultaneous pancreas-kidney transplant (SPKt) in Black and White patients to identify disparities in transplantation, days on the waitlist, and reasons for SPKt waitlist removal. METHODS Using the United Network for Organ Sharing Standard Transplant Analysis and Research file, patients between January 1, 2009, and May 31, 2021, were included. Three cohorts (overall, SPKt recipients only, and those not transplanted) were selected using propensity score matching. Conditional logistic regression was used for categorical outcomes. Days on the waitlist were compared using negative binomial regression. RESULTS Black patients had increased odds of receiving a SPKt (OR, 1.25 [95% CI, 1.11-1.40], p < 0.001). White patients had increased odds of receiving a kidney-only transplant (OR 0.48 [95% CI, 0.38-0.61], p < 0.001), and specifically increased odds of receiving a living donor kidney (OR 0.34 [0.25-0.45], p < 0.001). CONCLUSION This study found that Black patients are more likely to receive a SPKt. Results suggest that there are opportunities for additional inquiry related to patient removal from the waitlist, particularly considering White patients received or accepted more kidney-only transplants and were more likely to receive a living donor kidney-only transplant.
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Affiliation(s)
- Shawna M Green
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, Florida, USA
| | - Aaron C Spaulding
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, Florida, USA
| | - Emily R Brennan
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, Florida, USA
| | - Tambi Jarmi
- Mayo Clinic College of Medicine and Science, Mayo Clinic, Jacksonville, Florida, USA
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2
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Hippen BE, Hart GM, Maddux FW. A Transplant-Inclusive Value-Based Kidney Care Payment Model. Kidney Int Rep 2024; 9:1590-1600. [PMID: 38899170 PMCID: PMC11184397 DOI: 10.1016/j.ekir.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/06/2024] [Accepted: 02/05/2024] [Indexed: 06/21/2024] Open
Abstract
In the United States, kidney care payment models are migrating toward value-based care (VBC) models incentivizing quality of care at lower cost. Current kidney VBC models will continue through 2026. We propose a future transplant-inclusive VBC (TIVBC) model designed to supplement current models focusing on patients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD). The proposed TIVBC is structured as an episode-of-care model with risk-based reimbursement for "referral/evaluation/waitlisting" (REW, referencing kidney transplantation), "primary hospitalization to 180 days posttransplant," and "long-term graft survival." Challenges around organ acquisition costs, adjustments to quality metrics, and potential criticisms of the proposed model are discussed. We propose next steps in risk-adjustment and cost-prediction to develop as an end-to-end, TIVBC model.
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Affiliation(s)
- Benjamin E. Hippen
- Global Medical Office, Fresenius Medical Care, Waltham, Massachusetts, USA
| | | | - Franklin W. Maddux
- Global Medical Office, Fresenius Medical Care, Waltham, Massachusetts, USA
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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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4
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Asfour NW, Zhang KC, Lu J, Reese PP, Saunders M, Peek M, White M, Persad G, Parker WF. Association of Race and Ethnicity With High Longevity Deceased Donor Kidney Transplantation Under the US Kidney Allocation System. Am J Kidney Dis 2024:S0272-6386(24)00717-0. [PMID: 38636649 DOI: 10.1053/j.ajkd.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 02/02/2024] [Accepted: 02/08/2024] [Indexed: 04/20/2024]
Abstract
RATIONALE & OBJECTIVE The US Kidney Allocation System (KAS) prioritizes candidates with a≤20% estimated posttransplant survival (EPTS) to receive high-longevity kidneys defined by a≤20% Kidney Donor Profile Index (KDPI). Use of EPTS in the KAS deprioritizes candidates with older age, diabetes, and longer dialysis durations. We assessed whether this use also disadvantages race and ethnicity minority candidates, who are younger but more likely to have diabetes and longer durations of kidney failure requiring dialysis. STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS Adult candidates for and recipients of kidney transplantation represented in the Scientific Registry of Transplant Recipients from January 2015 through December 2020. EXPOSURE Race and ethnicity. OUTCOME Age-adjusted assignment to≤20% EPTS, transplantation of a≤20% KDPI kidney, and posttransplant survival in longevity-matched recipients by race and ethnicity. ANALYTIC APPROACH Multivariable logistic regression, Fine-Gray competing risks survival analysis, and Kaplan-Meier and Cox proportional hazards methods. RESULTS The cohort included 199,444 candidates (7% Asian, 29% Black, 19% Hispanic or Latino, and 43% White) listed for deceased donor kidney transplantation. Non-White candidates had significantly higher rates of diabetes, longer dialysis duration, and were younger than White candidates. Adjusted for age, Asian, Black, and Hispanic or Latino candidates had significantly lower odds of having a ETPS score of≤20% (odds ratio, 0.86 [95% CI, 0.81-0.91], 0.52 [95% CI, 0.50-0.54], and 0.49 [95% CI, 0.47-0.51]), and were less likely to receive a≤20% KDPI kidney (sub-hazard ratio, 0.70 [0.66-0.75], 0.89 [0.87-0.92], and 0.73 [0.71-0.76]) compared with White candidates. Among recipients with≤20% EPTS scores transplanted with a≤20% KDPI deceased donor kidney, Asian and Hispanic recipients had lower posttransplant mortality (HR, 0.45 [0.27-0.77] and 0.63 [0.47-0.86], respectively) and Black recipients had higher but not statistically significant posttransplant mortality (HR, 1.22 [0.99-1.52]) compared with White recipients. LIMITATIONS Provider reported race and ethnicity data and 5-year post transplant follow-up period. CONCLUSIONS The US kidney allocation system is less likely to identify race and ethnicity minority candidates as having a≤20% EPTS score, which triggers allocation of high-longevity deceased donor kidneys. These findings should inform the Organ Procurement and Transplant Network about how to remedy the race and ethnicity disparities introduced through KAS's current approach of allocating allografts with longer predicted longevity to recipients with longer estimated posttransplant survival. PLAIN-LANGUAGE SUMMARY The US Kidney Allocation System prioritizes giving high-longevity, high-quality kidneys to patients on the waiting list who have a high estimated posttransplant survival (EPTS) score. EPTS is calculated based on the patient's age, whether the patient has diabetes, whether the patient has a history of organ transplantation, and the number of years spent on dialysis. Our analyses show that Asian, Black or African American, and Hispanic or Latino patients were less likely to receive high-longevity kidneys compared with White patients, despite having similar or better posttransplant survival outcomes.
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Affiliation(s)
- Nour W Asfour
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Kevin C Zhang
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Jessica Lu
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Peter P Reese
- Department of Medicine, Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Milda Saunders
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Monica Peek
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Molly White
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Govind Persad
- Sturm College of Law, University of Denver, Denver, Colorado
| | - William F Parker
- Department of Medicine, University of Chicago, Chicago, Illinois; MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois; Department of Public Health Sciences, University of Chicago, Chicago, Illinois.
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Ford CG, Leyva Y, Kruger ES, Zhu Y, Croswell E, Kendall K, Puttarajapa C, Dew MA, Ng YH, Unruh ML, Myaskovsky L. Predicting Kidney Transplant Evaluation Non-attendance. J Clin Psychol Med Settings 2024; 31:153-162. [PMID: 36959431 PMCID: PMC10035980 DOI: 10.1007/s10880-023-09953-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/25/2023]
Abstract
Non-attendance to kidney transplant evaluation (KTE) appointments is a barrier to optimal care for those with kidney failure. We examined the medical and socio-cultural factors that predict KTE non-attendance to identify opportunities for integrated medical teams to intervene. Patients scheduled for KTE between May, 2015 and June, 2018 completed an interview before their initial KTE appointment. The interview assessed various social determinants of health, including demographic (e.g., income), medical (e.g. co-morbidities), transplant knowledge, cultural (e.g., medical mistrust), and psychosocial (e.g., social support) factors. We used multiple logistic regression analysis to determine the strongest predictor of KTE non-attendance. Our sample (N = 1119) was 37% female, 76% non-Hispanic White, median age 59.4 years (IQR 49.2-67.5). Of note, 142 (13%) never attended an initial KTE clinic appointment. Being on dialysis predicted higher odds of KTE non-attendance (OR 1.76; p = .02; 64% of KTE attendees on dialysis vs. 77% of non-attendees on dialysis). Transplant and nephrology teams should consider working collaboratively with dialysis units to better coordinate care, (e.g., resources to attend appointment or outreach to emphasize the importance of transplant) adjusting the KTE referral and evaluation process to address access issues (e.g., using tele-health) and encouraging partnership with clinical psychologists to promote quality of life for those on dialysis.
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Affiliation(s)
- C Graham Ford
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Yuridia Leyva
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Eric S Kruger
- Department of Physical Therapy, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Yiliang Zhu
- Department of Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, USA
| | - Emilee Croswell
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, USA
| | | | - Chethan Puttarajapa
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Mary Amanda Dew
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Yue Harn Ng
- Department of Internal Medicine, University of Washington, Seattle, USA
| | - Mark L Unruh
- Department of Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, USA
| | - Larissa Myaskovsky
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Sciences Center, Albuquerque, USA.
- Department of Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, USA.
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6
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Hoffman AL, Westphal SG, Wekesa D, Miles CD. Impact of OPTN policy 3.7D providing waiting time modification for candidates affected by race-inclusive eGFR calculations: Early results from a single center. Clin Transplant 2024; 38:e15273. [PMID: 38516921 DOI: 10.1111/ctr.15273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/04/2024] [Accepted: 02/12/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION OPTN Policy 3.7D, implemented January 5, 2023, mandates that all kidney transplant programs modify waiting time for candidates affected by race-inclusive eGFR calculations. We report the early impact of this policy change. METHODS Our transplant program reviewed all listed transplant candidates and identified patients potentially eligible for waiting time modification. Eligible candidates received waiting time modification after submission of supporting evidence to the OPTN. We reviewed the impact on waiting time and transplant activity through October 1, 2023. RESULTS Forty-six adult patients on our center's active waiting list self-identified as Black/African American. 25 (54.3%) candidates qualified for waiting time modification. A median 451 (321, 1543.5) additional days of waiting time was added for qualifying patients. Of the 25 patients who qualified for waiting time modification, 11 patients received a deceased donor kidney in the early period following waiting time modification, including 5 patients transplanted within 1 month after modification. CONCLUSIONS Policy 3.7D is one of few national mandates to address specifically structural racism within transplantation. Implementation has yielded near immediate effects with greater than 40% of time-adjusted patients at our center receiving a deceased donor kidney transplant in the initial months after policy enactment. Early assessment demonstrates great potential impact for this policy.
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Affiliation(s)
- Arika L Hoffman
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Scott G Westphal
- Nebraska Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Debra Wekesa
- Nebraska Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Clifford D Miles
- Nebraska Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Cacciola R, Leonardis F, Gitto L, Favi E, Gruttadauria S, Clancy M, Veroux M, Angelico R, Pagano D, Mazzeo C, Cacciola I, Santoro D, Toti L, Tisone G, Cucinotta E. Health economics aspects of kidney transplantation in Sicily: a benchmark analysis on activity and estimated savings. Front Public Health 2023; 11:1222069. [PMID: 38162608 PMCID: PMC10757609 DOI: 10.3389/fpubh.2023.1222069] [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: 05/13/2023] [Accepted: 11/24/2023] [Indexed: 01/03/2024] Open
Abstract
Background International and national registries consistently report substantial differences in kidney transplant (KT) activity despite demonstrable clinical and financial benefits. The study aims to estimate the financial resources gained by KT and produce a benchmark analysis that would inform adequate strategies for the growth of the service. Methods We analyzed the KT activity in our region between 2017 and 2019. The benchmark analysis was conducted with programs identified from national and international registries. The estimate of financial resources was obtained by applying the kidney transplant coefficient of value; subsequently, we compared the different activity levels and savings generated by the three KT programs. Findings The KT activity in the region progressively declined in the study years, producing a parallel reduction of the estimated savings. Such savings were substantially inferior when compared to those generated by benchmark programs (range €18-22 million less). Interpretation The factors influencing the reduced KT activity in the study period with the related "foregone savings" are multiple, as well as interdependent. Organ donation, access to the transplant waiting list, and KT from living donors appear to be the most prominent determinants of the observed different levels of activities. International experience suggests that a comprehensive strategy in the form of a "task force" may successfully address the critical areas of the service reversing the observed trend. The financial impact of a progressively reduced KT activity may be as critical as its clinical implications, jeopardizing the actual sustainability of services for patients with end-stage kidney disease.
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Affiliation(s)
- Roberto Cacciola
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
| | - Francesca Leonardis
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
- Intensive Care Unit, Organ and Tissue Procurement Policlinico Tor Vergata, Rome, Italy
| | - Lara Gitto
- Dipartimento di Economia, Università Degli Studi di Messina, Messina, Italy
| | - Evaldo Favi
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Clinical Sciences and Community Health, Università Degli Studi di Milano, Milan, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, University of Istituto di Ricovero e Cura a Carattere Scientifico – Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, University of Pittsburgh Medical Center Italy, Palermo, Italy
- Department of Surgery and Surgical and Medical Specialties, University of Catania, Catania, Italy
| | - Marc Clancy
- Institute of Cardiovascular and Molecular Sciences, Glasgow University, Glasgow, United Kingdom
| | - Massimiliano Veroux
- General Surgery Unit, Organ Transplant Unit, University Hospital of Catania, Catania, Italy
| | - Roberta Angelico
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
| | - Duilio Pagano
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, University of Istituto di Ricovero e Cura a Carattere Scientifico – Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, University of Pittsburgh Medical Center Italy, Palermo, Italy
| | - Carmelo Mazzeo
- Department of Human Pathology, Emergency Surgery Unit, Università Degli Studi di Messina, Messina, Italy
| | - Irene Cacciola
- Department of Clinical and Experimental Medicine, Medicine and Hepatology Unit, Università Degli Studi di Messina, Messina, Italy
| | - Domenico Santoro
- Department of Clinical and Experimental Medicine, Nephrology and Dialysis Unit, Università Degli Studi di Messina, Messina, Italy
| | - Luca Toti
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
| | - Giuseppe Tisone
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
| | - Eugenio Cucinotta
- General Surgery Unit, Organ Transplant Unit, University Hospital of Catania, Catania, Italy
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8
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Spardy J, Concepcion J, Yeager M, Andrade R, Braun H, Elkbuli A. National Analysis of Recent Trends in Organ Donation and Transplantation in the United States: Toward Optimizing Care Delivery and Patient Outcomes. Am Surg 2023; 89:5201-5209. [PMID: 36423909 DOI: 10.1177/00031348221135776] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
INTRODUCTION In 2021, over 100 000 people were awaiting solid organ transplantation, yet only 44 634 transplants were performed. The aim of this study is to evaluate trends in donor availability, waitlist additions, and transplants performed in the United States from 2001 to 2021. METHODS This was a retrospective analysis to evaluate trends in donor availability, waitlist additions, and solid organ transplants for the 4 most common organs requiring transplants (kidney, liver, heart, and lung) between 2001 and 2021 according to OPTN data. RESULTS Between 2001 and 2021, the overall number of transplants performed, donors available, and waitlist additions increased by 71%, 61%, and 54%, respectively. The number of kidney transplant waitlist additions significantly increased compared to other organs (P < .001). For each kidney transplant performed, there was a 2.25 increase in waitlist additions throughout the study period (P < .001). For each liver and heart transplant performed, there was a .92 and .80 increase in waitlist additions, respectively (P < .001). Lung transplants increased the most by 138% and there was an increase in waitlist additions for every transplant by 1.0 (P < .001). CONCLUSION There was an absolute increase in the annual number of transplants, donor recruitment, and patients added to the waitlist between 2001 and 2021. Kidney transplant waitlist additions are increasing at a rate outpacing the rates of donor recruitment and transplantation.
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Affiliation(s)
- Jeffrey Spardy
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | | | - Matthew Yeager
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Ryan Andrade
- A.T. Still University School of Osteopathic Medicine, Mesa, AZ, USA
| | - Hillary Braun
- Department of Surgery, Zuckerberg General Hospital and Trauma Center, San Francisco, CA, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
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9
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Schold JD, Huml AM, Husain SA, Mohan S. Why the National Academies Got it Wrong about Changing Preemptive Listing Priority for Kidney Transplantation. J Am Soc Nephrol 2023; 34:1615-1617. [PMID: 37782624 PMCID: PMC10561815 DOI: 10.1681/asn.0000000000000209] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/03/2023] [Indexed: 07/26/2023] Open
Affiliation(s)
- Jesse D. Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Anne M. Huml
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio
| | - S. Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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10
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Adler JT, Han HS, Lee BK. Persistent Disparities in Waitlisting After the Kidney Allocation System: Are We Exacerbating the Problem? Kidney Med 2023; 5:100716. [PMID: 37711885 PMCID: PMC10498295 DOI: 10.1016/j.xkme.2023.100716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Affiliation(s)
- Joel T. Adler
- Division of Transplantation, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, TX
| | - Hwarang S. Han
- Department of Medicine, Dell Medical School at the University of Texas at Austin, Austin, TX
| | - Brian K. Lee
- Department of Medicine, Dell Medical School at the University of Texas at Austin, Austin, TX
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11
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Thongprayoon C, Tangpanithandee S, Jadlowiec CC, Mao SA, Mao MA, Vaitla P, Acharya PC, Leeaphorn N, Kaewput W, Pattharanitima P, Suppadungsuk S, Krisanapan P, Nissaisorakarn P, Cooper M, Craici IM, Cheungpasitporn W. Characteristics of Kidney Transplant Recipients with Prolonged Pre-Transplant Dialysis Duration as Identified by Machine Learning Consensus Clustering: Pathway to Personalized Care. J Pers Med 2023; 13:1273. [PMID: 37623523 PMCID: PMC10455164 DOI: 10.3390/jpm13081273] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 08/26/2023] Open
Abstract
Longer pre-transplant dialysis duration is known to be associated with worse post-transplant outcomes. Our study aimed to cluster kidney transplant recipients with prolonged dialysis duration before transplant using an unsupervised machine learning approach to better assess heterogeneity within this cohort. We performed consensus cluster analysis based on recipient-, donor-, and transplant-related characteristics in 5092 kidney transplant recipients who had been on dialysis ≥ 10 years prior to transplant in the OPTN/UNOS database from 2010 to 2019. We characterized each assigned cluster and compared the posttransplant outcomes. Overall, the majority of patients with ≥10 years of dialysis duration were black (52%) or Hispanic (25%), with only a small number (17.6%) being moderately sensitized. Within this cohort, three clinically distinct clusters were identified. Cluster 1 patients were younger, non-diabetic and non-sensitized, had a lower body mass index (BMI) and received a kidney transplant from younger donors. Cluster 2 recipients were older, unsensitized and had a higher BMI; they received kidney transplant from older donors. Cluster 3 recipients were more likely to be female with a higher PRA. Compared to cluster 1, cluster 2 had lower 5-year death-censored graft (HR 1.40; 95% CI 1.16-1.71) and patient survival (HR 2.98; 95% CI 2.43-3.68). Clusters 1 and 3 had comparable death-censored graft and patient survival. Unsupervised machine learning was used to characterize kidney transplant recipients with prolonged pre-transplant dialysis into three clinically distinct clusters with variable but good post-transplant outcomes. Despite a dialysis duration ≥ 10 years, excellent outcomes were observed in most recipients, including those with moderate sensitization. A disproportionate number of minority recipients were observed within this cohort, suggesting multifactorial delays in accessing kidney transplantation.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (S.S.); (P.K.); (I.M.C.); (W.C.)
| | - Supawit Tangpanithandee
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (S.S.); (P.K.); (I.M.C.); (W.C.)
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan 10540, Thailand
| | - Caroline C. Jadlowiec
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Shennen A. Mao
- Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ 85054, USA;
| | - Michael A. Mao
- Division of Transplant Surgery, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - Pradeep Vaitla
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - Prakrati C. Acharya
- Division of Nephrology, Texas Tech Health Sciences Center El Paso, El Paso, TX 79905, USA;
| | - Napat Leeaphorn
- Renal Transplant Program, University of Missouri-Kansas City School of Medicine/Saint Luke’s Health System, Kansas City, MO 64108, USA;
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand;
| | - Pattharawin Pattharanitima
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine Thammasat University, Pathum Thani 12120, Thailand;
| | - Supawadee Suppadungsuk
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (S.S.); (P.K.); (I.M.C.); (W.C.)
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan 10540, Thailand
| | - Pajaree Krisanapan
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (S.S.); (P.K.); (I.M.C.); (W.C.)
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine Thammasat University, Pathum Thani 12120, Thailand;
- Division of Nephrology, Department of Internal Medicine, Thammasat University Hospital, Pathum Thani 12120, Thailand
| | - Pitchaphon Nissaisorakarn
- Deparment of Medicine, Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA;
| | - Matthew Cooper
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA;
| | - Iasmina M. Craici
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (S.S.); (P.K.); (I.M.C.); (W.C.)
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (S.S.); (P.K.); (I.M.C.); (W.C.)
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12
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Matas AJ, Montgomery RA, Schold JD. The Organ Shortage Continues to Be a Crisis for Patients With End-stage Kidney Disease. JAMA Surg 2023; 158:787-788. [PMID: 37223921 DOI: 10.1001/jamasurg.2023.0526] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
This Viewpoint describes the organ shortage for patients with end-stage kidney disease despite increases in kidney donations between 2000 and 2021.
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Affiliation(s)
- Arthur J Matas
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis
| | | | - Jesse D Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora
- Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora
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13
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Merweland RV, Busschbach JJV, van de Wetering J, Ismail S. Paving the way for solutions improving access to kidney transplantation: a qualitative study from a multistakeholder perspective. BMJ Open 2023; 13:e071483. [PMID: 37263692 DOI: 10.1136/bmjopen-2022-071483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
OBJECTIVES The aim of this study was to obtain an in-depth perspective from stakeholders involved in access to kidney transplantation to pave the way for solutions in improving access to kidney transplantation. This study qualitatively explored factors influencing optimal access to kidney transplantation from a broad stakeholder perspective. DESIGN A qualitative study was performed using semistructured interviews both in focus groups and with individual participants. All interviews were recorded, transcribed and coded according to the principles of grounded theory. SETTING Participants were healthcare providers (geographically spread), patients and (former living) kidney donors, policy-makers and insurers. PARTICIPANTS Stakeholders (N=87) were interviewed regarding their perceptions, opinions and attitudes regarding access to kidney transplantation. RESULTS The problems identified by stakeholders within the domains-policy, medical, psychological, social and economic-were acknowledged by all respondents. According to respondents, more efforts should be made to make healthcare providers and patients aware of the clinical guideline for kidney transplantation. The same opinion applied to differences in medical inclusion criteria used in the different transplantation centres. Stakeholders saw room for improvement based on psychological and social themes, especially regarding the provision of information. Many stakeholders described the need to rethink the current economic model to improve access to kidney transplantation. This discussion led to a definition of the most urgent problems for which, according to the respondents, a solution must be sought to optimise access to kidney transplantation. CONCLUSIONS Stakeholders indicated a high sense of urgency to solve barriers in patient access to kidney transplantation. Moreover, it appears that some barriers are quite straightforward to overcome; according to stakeholders, it is striking that this process has not yet been overcome. Stakeholders involved in kidney transplantation have provided directions for future solutions, and now it is possible to search for solutions with them.
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Affiliation(s)
- Ruben van Merweland
- Department of Psychiatry, Section of Medical Psychology and Psychotherapy, Erasmus MC, Rotterdam, The Netherlands
| | - Jan J V Busschbach
- Department of Psychiatry, Section of Medical Psychology and Psychotherapy, Erasmus MC, Rotterdam, The Netherlands
| | - Jacqueline van de Wetering
- Department of Internal Medicine, Nephrology, and Transplantation, Erasmus MC, Rotterdam, The Netherlands
| | - Sohal Ismail
- Department of Psychiatry, Section of Medical Psychology and Psychotherapy, Erasmus MC, Rotterdam, The Netherlands
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14
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Nguyen NTQ, Courtney AE, Nguyen HQ, Quinn M, Maxwell AP, O'Neill C. Early clinical and economic outcomes of expanded criteria living kidney donors in the United States. J Nephrol 2023; 36:957-968. [PMID: 36592302 DOI: 10.1007/s40620-022-01541-4] [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: 08/22/2022] [Accepted: 11/20/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND The donation of what might be termed expanded criteria kidneys has become an increasingly common practice. This study aimed to assign expanded criteria and non-expanded criteria donation status and examine early clinical and economic outcomes among expanded criteria and non-expanded criteria living kidney donor (LKD) hospitalizations in the US. METHODS Healthcare cost and Utilization Project-National (Nationwide) Inpatient Sample (HCUP-NIS) data (Jan 2008-Dec 2019, N = 12,020) were used. Expanded criteria LKDs were identified as admitted patients aged ≥ 60 years, or 50-59 years with any comorbidity that historically precluded donation. The Clavien-Dindo system was applied to classify surgical complications as grade I-IV/V. RESULTS The number of LKD admissions decreased by 31% over the study period, although this trend fluctuated over time. Compared to non-expanded criteria LKD admissions, expanded criteria LKD admissions had comparable surgical complication rates in Grade I (aOR 1.0, 0.8-1.3), but significantly higher surgical complication rates in Grade II (aOR 1.5, 1.1-2.2) and Grade III (aOR 1.4, 1.0-2.0). The two groups had comparable hospital length of stay and cost in the adjusted models. Notably, Grade II complications were significantly higher in private, for-profit hospitals (15%) compared to government hospitals (2.9%). CONCLUSIONS Expanded criteria LKDs had comparable early outcomes compared to non-expanded criteria LKDs, but the trends evident in LKDs over time and the variation in complication records warrant further research.
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Affiliation(s)
- Nga T Q Nguyen
- Faculty of Pharmacy, University of Medicine and Pharmacy at Ho Chi Minh City, 41-43 Dinh Tien Hoang Street, Ben Nghe Ward, District 1, Ho Chi Minh City, Vietnam.
| | - Aisling E Courtney
- Regional Nephrology and Transplant Unit, Belfast City Hospital, Belfast, UK
| | - Hoa Q Nguyen
- Faculty of Pharmacy, University of Medicine and Pharmacy at Ho Chi Minh City, 41-43 Dinh Tien Hoang Street, Ben Nghe Ward, District 1, Ho Chi Minh City, Vietnam
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Michael Quinn
- Regional Nephrology and Transplant Unit, Belfast City Hospital, Belfast, UK
| | - Alexander P Maxwell
- Belfast City Hospital, Belfast, UK
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Ciaran O'Neill
- Centre for Public Health, Queen's University Belfast, Belfast, UK
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15
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Ernst Z, Wilson A, Peña A, Love M, Moore T, Vassar M. Factors associated with health inequities in access to kidney transplantation in the USA: A scoping review. Transplant Rev (Orlando) 2023; 37:100751. [PMID: 36958131 DOI: 10.1016/j.trre.2023.100751] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 02/22/2023] [Accepted: 02/25/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND The kidney is the most needed organ for transplantation in the United States. However, demand and scarcity of this organ has caused significant inequities for historically marginalized groups. In this review, we report on the frequency of inequities in all steps of kidney transplantation from 2016 to 2022. Search criteria was based on the National Institute of Health's (NIH) 2022 list of populations who experience health inequities, which includes: race and ethnicity; sex or gender; Lesbian, Gay, Bisexual, Transgender, Queer + (LGBTQ+); underserved rural communities; education level; income; and occupation status. We outline steps for future research aimed at assessing interventions and programs to improve health outcomes. METHODS This scoping review was developed following guidelines from the Joanna Briggs Institute and PRISMA extension for scoping reviews. In July 2022, we searched Medline (via PubMed) and Ovid Embase databases to identify articles addressing inequities in access to kidney transplantation in the United States. Articles had to address at least one of the NIH's 2022 health inequity groups. RESULTS Our sample of 44 studies indicate that Black race, female sex or gender, and low socioeconomic status are negatively associated with referral, evaluation, and waitlisting for kidney transplantation. Furthermore, only two studies from our sample investigated LGBTQ+ identity since the NIH's addition of SGM in 2016 regarding access to transplantation. Lastly, we found no detectable trend in studies for the four most investigated inequity groups between 2016 and 2022. CONCLUSION Investigations in inequities for access to kidney transplantation for the two most studied groups, race/ethnicity and sex or gender, have shown no change in frequencies. Regarding race and ethnicity, continued interventions focused on educating Black patients and staff of dialysis facilities may increase transplant rates. Studies aimed at assessing effectiveness of the Kidney Paired Donation program are highly warranted due to incompatibility problems in female patients. The sparse representation for the LGBTQ+ population may be due to a lack of standardized data collection for sexual orientation. We recommend this community be engaged via surveys and further investigations.
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Affiliation(s)
- Zachary Ernst
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America.
| | - Andrew Wilson
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America
| | - Andriana Peña
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America
| | - Mitchell Love
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America
| | - Ty Moore
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America
| | - Matt Vassar
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America; Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America.
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16
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Morenz A, Perkins J, Dick A, Young B, Ng YH. Reexamining the Impact of Insurance Type on Kidney Transplant Waitlist Status and Posttransplantation Outcomes in the United States After Implementation of the Affordable Care Act. Transplant Direct 2023; 9:e1442. [PMID: 36743233 PMCID: PMC9891441 DOI: 10.1097/txd.0000000000001442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 11/21/2022] [Accepted: 12/15/2022] [Indexed: 01/27/2023] Open
Abstract
Insurance type, a marker of socioeconomic status, has been associated with poor access to kidney transplant (KT) and worse KT outcomes before the implementation of the Affordable Care Act (ACA) and the revised Kidney Allocation System (KAS). In this study, we assessed if insurance type remained a risk marker for worse waitlist and transplant outcomes after ACA and KAS. Methods Using Scientific Registry of Transplant Recipients data, we assessed insurance type of waitlisted candidates pre- (2008-2014) versus post- (2014-2021) KAS/ACA using chi-square tests. Next, we performed a competing risk analysis to study the effect of private versus public (Medicare, Medicaid, or government-sponsored) insurance on waitlist outcomes and a Cox survival analysis to study posttransplant outcomes while controlling for candidate, and recipient and donor variables, respectively. Results The proportion of overall KT candidates insured by Medicaid increased from pre-KAS/ACA to post-KAS/ACA (from 12 667 [7.3%] to 21 768 [8.8%], P < 0.0001). However, KT candidates with public insurance were more likely to have died or become too sick for KT (subdistribution hazard ratio [SHR] = 1.33, confidence interval [CI], 1.30-1.36) or to receive a deceased donor KT (SHR = 1.57, CI, 1.54-1.60) but less likely to receive a living donor KT (SHR = 0.87, CI, 0.85-0.89). Post-KT, KT recipients with public insurance had greater risk of mortality (relative risks = 1.22, CI, 1.15-1.31) and allograft failure (relative risks = 1.10, CI, 1.03-1.29). Conclusions Although the implementation of ACA marginally increased the proportion of waitlisted candidates with Medicaid, publicly insured KT candidates remained at greater risk of being removed from the waitlist, had lower probability of living donor kidney transplantation, and had greater probability of dying post-KT and allograft failure. Concerted efforts to address factors contributing to these inequities in future studies are needed, with the goal of achieving equity in KT for all.
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Affiliation(s)
- Anna Morenz
- Department of Medicine, University of Washington, Seattle, WA
| | - James Perkins
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), Department of Surgery, University of Washington, Seattle, WA
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, WA
| | - André Dick
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), Department of Surgery, University of Washington, Seattle, WA
- Division of Transplantation, Department of Surgery, Seattle Children’s Hospital, Seattle, WA
| | - Bessie Young
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Yue-Harn Ng
- Clinical and Bio-Analytics Transplant Laboratory (CBATL), Department of Surgery, University of Washington, Seattle, WA
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
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17
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Stewart D, Mupfudze T, Klassen D. Does anybody really know what (the kidney median waiting) time is? Am J Transplant 2023; 23:223-231. [PMID: 36695688 DOI: 10.1016/j.ajt.2022.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/10/2022] [Accepted: 12/05/2022] [Indexed: 01/13/2023]
Abstract
The median waiting time (MWT) to deceased donor kidney transplant is of interest to patients, clinicians, and the media but remains elusive due to both methodological and philosophical challenges. We used Organ Procurement and Transplantation Network data from January 2003 to March 2022 to estimate MWTs using various methods and timescales, applied overall, by era, and by candidate demographics. After rising for a decade, the overall MWT fell to 5.19 years between 2015 and 2018 and declined again to 4.05 years (April 2021 to March 2022), based on the Kaplan-Meier method applied to period-prevalent cohorts. MWTs differed markedly by blood type, donor service area, and pediatric vs adult status, but to a lesser degree by race/ethnicity. Choice of methodology affected the magnitude of these differences. Instead of waiting years for an answer, reliable kidney MWT estimates can be obtained shortly after a policy is implemented using the period-prevalent Kaplan-Meier approach, a theoretical but useful construct for which we found no evidence of bias compared with using incident cohorts. We recommend this method be used complementary to the competing risks approach, under which MWT is often inestimable, to fill the present information void concerning the seemingly simple question of how long it takes to get a kidney transplant in the United States.
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Affiliation(s)
| | | | - David Klassen
- Office of the Chief Medical Officer, United Network for Organ Sharing
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18
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Zaphiros NH, Nie J, Chang S, Shah V, Kareem S, Zaaroura A, Kayler LK. Broad organ acceptance and equitable access to early kidney transplantation. Clin Transplant 2023; 37:e14916. [PMID: 36638138 DOI: 10.1111/ctr.14916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 12/23/2022] [Accepted: 01/10/2023] [Indexed: 01/14/2023]
Abstract
BACKGROUND Broad organ acceptance can increase early kidney transplantation (KTX) within <1-year of dialysis initiation while improving access inequity. METHODS Single-center data of adult isolated deceased-donor KTX recipients between 2013 and 2020 were stratified into three 2.5-year periods before-, early after-, and late after our center's deceased-donor organ acceptance practice change, excluding a 6-month implementation period. Outcomes were assessed within five recipient subgroups based on demographic and clinical characteristics. RESULTS Of 704 recipients, the frequency of early KTX was 22% pre-change, 36% early post-change, and 34% late post-change. Given similar post-change frequencies of early KTX, post-change eras were combined to improve analytic power of subgroup analyses. After the organ acceptance practice change (vs. pre-change), the likelihood of early KTX increased variably within historically underserved groups, including recipients who were older (37%-39%, p = .859), Black (10%-21%, p = .136), female (21%-37%, p = .034), diabetic (13%-32%, p = .010), and BMI≥35 kg/m2 (20%-34%, p = .007). Despite the practice change, Black recipients continued to experience less early KTX compared to non-Black recipients. The likelihood of delayed graft function was significantly increased (p < .001), and 1-year creatinine was significantly higher (p < .001) post-practice change, but between-era risk-adjusted death-censored graft survival was similar. CONCLUSIONS Transition to broader donor acceptance was associated with more early KTXs among historically underserved patient subgroups. However, the effect was non-significant among Black recipients, suggesting the need for additional strategies to impact early transplant access for this population. Studies of broad organ acceptance are needed to examine both access and outcomes.
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Affiliation(s)
- Nikolas H Zaphiros
- Department of Surgery, University at Buffalo, Buffalo, New York, USA.,Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, Buffalo, New York, USA
| | - Jing Nie
- Department of Epidemiology and Environmental Health, University at Buffalo School of Public Health and Health Professions, Buffalo, New York, USA
| | - Shirley Chang
- Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, Buffalo, New York, USA.,Department of Medicine, University at Buffalo, Buffalo, New York, USA
| | - Vaqar Shah
- Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, Buffalo, New York, USA.,Department of Medicine, University at Buffalo, Buffalo, New York, USA
| | - Samer Kareem
- Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, Buffalo, New York, USA.,Department of Medicine, University at Buffalo, Buffalo, New York, USA
| | - Ahmad Zaaroura
- Department of Surgery, University at Buffalo, Buffalo, New York, USA.,Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, Buffalo, New York, USA
| | - Liise K Kayler
- Department of Surgery, University at Buffalo, Buffalo, New York, USA.,Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, Buffalo, New York, USA.,Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, New York, USA
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19
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Patzer RE, Di M, Zhang R, McPherson L, DuBay DA, Ellis M, Wolf J, Jones H, Zayas C, Mulloy L, Reeves-Daniel A, Mohan S, Perez AC, Trivedi AN, Pastan SO. Referral and Evaluation for Kidney Transplantation Following Implementation of the 2014 National Kidney Allocation System. Am J Kidney Dis 2022; 80:707-717. [PMID: 35301050 PMCID: PMC9470777 DOI: 10.1053/j.ajkd.2022.01.423] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 01/03/2022] [Indexed: 02/02/2023]
Abstract
RATIONALE & OBJECTIVE The national kidney allocation system (KAS) implemented in December 2014 in the United States redefined the start of waiting time from the time of waitlisting to the time of kidney failure. Waitlisting has declined post-KAS, but it is unknown if this is due to transplant center practices or changes in dialysis facility referral and evaluation. The purpose of this study was to assess the impact of the 2014 KAS policy change on referral and evaluation for transplantation among a population of incident and prevalent patients with kidney failure. STUDY DESIGN Cohort study. SETTING & PARTICIPANTS 37,676 incident (2012-2016) patients in Georgia, North Carolina, and South Carolina identified within the US Renal Data System at 9 transplant centers and followed through December 2017. A prevalent population of 6,079 patients from the same centers receiving maintenance dialysis in 2012 but not referred for transplantation in 2012. EXPOSURE KAS era (pre-KAS vs post-KAS). OUTCOME Referral for transplantation, start of transplant evaluation, and waitlisting. ANALYTICAL APPROACH Multivariable time-dependent Cox models for the incident and prevalent population. RESULTS Among incident patients, KAS was associated with increased referrals (adjusted HR, 1.16 [95% CI, 1.12-1.20]) and evaluation starts among those referred (adjusted HR, 1.16 [95% CI, 1.10-1.21]), decreased overall waitlisting (adjusted HR, 0.70 [95% CI, 0.65-0.76]), and lower rates of active waitlisting among those evaluated compared to the pre-KAS era (adjusted HR, 0.81 [95% CI, 0.74-0.90]). Among the prevalent population, KAS was associated with increases in overall waitlisting (adjusted HR, 1.74 [95% CI, 1.15-2.63]) and active waitlisting among those evaluated (adjusted HR, 2.01 [95% CI, 1.16-3.49]), but had no significant impact on referral or evaluation starts among those referred. LIMITATIONS Limited to 3 states, residual confounding. CONCLUSIONS In the southeastern United States, the impact of KAS on steps to transplantation was different among incident and prevalent patients with kidney failure. Dialysis facilities referred more incident patients and transplant centers evaluated more incident patients after implementation of KAS, but fewer evaluated patients were placed onto the waitlist. Changes in dialysis facility and transplant center behaviors after KAS implementation may have influenced the observed changes in access to transplantation.
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Affiliation(s)
- Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia; Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
| | - Mengyu Di
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia
| | - Rebecca Zhang
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Laura McPherson
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Derek A DuBay
- Medical University of South Carolina, Charleston, South Carolina
| | - Matthew Ellis
- Department of Medicine and Department of Surgery, Duke University, Durham, North Carolina
| | - Joshua Wolf
- Piedmont Transplant Institute, Piedmont Healthcare, Atlanta, Georgia
| | | | - Carlos Zayas
- Medical University of South Carolina, Charleston, South Carolina
| | - Laura Mulloy
- Division of Nephrology, Department of Medicine, Augusta University, Augusta, Georgia
| | | | - Sumit Mohan
- Departments of Medicine and Epidemiology, Columbia University Irving Medical Center, New York, New York
| | - Aubriana C Perez
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia
| | - Amal N Trivedi
- Brown University School of Public Health, Providence, Rhode Island; Center of Innovation in Long-term Services and Supports, Providence VA Medical Center, Providence, Rhode Island
| | - Stephen O Pastan
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia; Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia
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20
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Characteristics of Kidney Recipients of High Kidney Donor Profile Index Kidneys as Identified by Machine Learning Consensus Clustering. J Pers Med 2022; 12:jpm12121992. [PMID: 36556213 PMCID: PMC9782675 DOI: 10.3390/jpm12121992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/24/2022] [Accepted: 11/29/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Our study aimed to characterize kidney transplant recipients who received high kidney donor profile index (KDPI) kidneys using unsupervised machine learning approach. Methods: We used the OPTN/UNOS database from 2010 to 2019 to perform consensus cluster analysis based on recipient-, donor-, and transplant-related characteristics in 8935 kidney transplant recipients from deceased donors with KDPI ≥ 85%. We identified each cluster’s key characteristics using the standardized mean difference of >0.3. We compared the posttransplant outcomes among the assigned clusters. Results: Consensus cluster analysis identified 6 clinically distinct clusters of kidney transplant recipients from donors with high KDPI. Cluster 1 was characterized by young, black, hypertensive, non-diabetic patients who were on dialysis for more than 3 years before receiving kidney transplant from black donors; cluster 2 by elderly, white, non-diabetic patients who had preemptive kidney transplant or were on dialysis less than 3 years before receiving kidney transplant from older white donors; cluster 3 by young, non-diabetic, retransplant patients; cluster 4 by young, non-obese, non-diabetic patients who received dual kidney transplant from pediatric, black, non-hypertensive non-ECD deceased donors; cluster 5 by low number of HLA mismatch; cluster 6 by diabetes mellitus. Cluster 4 had the best patient survival, whereas cluster 3 had the worst patient survival. Cluster 2 had the best death-censored graft survival, whereas cluster 4 and cluster 3 had the worst death-censored graft survival at 1 and 5 years, respectively. Cluster 2 and cluster 4 had the best overall graft survival at 1 and 5 years, respectively, whereas cluster 3 had the worst overall graft survival. Conclusions: Unsupervised machine learning approach kidney transplant recipients from donors with high KDPI based on their pattern of clinical characteristics into 6 clinically distinct clusters.
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21
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Loor JM, Judd NS, Rice CM, Perea DD, Croswell E, Singh PP, Unruh M, Zhu Y, Sehgal AR, Goff SL, Bryce CL, Myaskovsky L. Protocol for the AKT-MP trial: Access to Kidney Transplantation in Minority Populations. Contemp Clin Trials Commun 2022; 30:101015. [PMID: 36246997 PMCID: PMC9562954 DOI: 10.1016/j.conctc.2022.101015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 09/02/2022] [Accepted: 10/01/2022] [Indexed: 11/01/2022] Open
Abstract
Background Kidney transplant (KT) is the optimal treatment for kidney failure (KF), and although completion of KT evaluation is an essential step in gaining access to transplantation, the process is lengthy, time consuming, and burdensome. Furthermore, despite similar referral rates to non-Hispanic Whites, both Hispanic/Latinos and American Indians are less likely to be wait-listed or to undergo KT. Methods The Access to Kidney Transplantation in Minority Populations (AKT-MP) Trial compares two patient-centered methods to facilitate KT evaluation: kidney transplant fast track (KTFT), a streamlined KT evaluation process; and peer navigators (PN), a peer-assisted evaluation program that incorporates motivational interviewing. This pragmatic randomized trial will use a comparative effectiveness approach to assess whether KTFT or PN can help patients overcome barriers to transplant listing. We will randomly assign patients to the two conditions. We will track participants' medical records and conduct surveys prior to their initial evaluation clinic visit and again after they complete or discontinue evaluation. Conclusion Our aims are to (1) compare KTFT and PN to assess improvements in kidney transplant (KT) related outcomes and cost effectiveness; (2) examine how each approach effects changes in cultural/contextual factors, KT concerns, KT knowledge, and KT ambivalence; and (3) develop a framework for widespread implementation of either approach. The results of this trial will provide key information for facilitating the evaluation process, improving patient care, and decreasing disparities in KT.
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Affiliation(s)
- Jamie M. Loor
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Science Center, United States
| | - Nila S. Judd
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Science Center, United States
| | - Claudia M. Rice
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Science Center, United States
| | - Diana D. Perea
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Science Center, United States
| | - Emilee Croswell
- Department of Psychiatry, University of Pittsburgh, United States
| | - Pooja P. Singh
- Department of Internal Medicine, University of New Mexico, School of Medicine, United States
| | - Mark Unruh
- Department of Internal Medicine, University of New Mexico, School of Medicine, United States
| | - Yiliang Zhu
- Department of Internal Medicine, University of New Mexico, School of Medicine, United States
| | - Ashwini R. Sehgal
- Department of Medicine, Case Western Reserve University, United States
| | - Sarah L. Goff
- Department of Health Policy and Management, University of Massachusetts, Amherst, United States
| | - Cindy L. Bryce
- Department of Health Policy and Management, University of Pittsburgh, School of Public Health, United States
| | - Larissa Myaskovsky
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Science Center, United States,Department of Internal Medicine, University of New Mexico, School of Medicine, United States,Corresponding author. Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Science Center, United States.
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22
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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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23
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Mohan S, Husain SA. Improving the Utilization of Deceased Donor Kidneys by Prioritizing Patient Preferences. Clin J Am Soc Nephrol 2022; 17:1278-1280. [PMID: 35985701 PMCID: PMC9625108 DOI: 10.2215/cjn.08500722] [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: 01/27/2023]
Affiliation(s)
- Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - S. Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York
- Columbia University Renal Epidemiology Group, New York, New York
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24
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Becerra AZ, Chan KE, Eggers PW, Norton J, Kimmel PL, Schulman IH, Mendley SR. Transplantation Mediates Much of the Racial Disparity in Survival from Childhood-Onset Kidney Failure. J Am Soc Nephrol 2022; 33:1265-1275. [PMID: 35078941 PMCID: PMC9257803 DOI: 10.1681/asn.2021071020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 01/13/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The role of kidney transplantation in differential survival in Black and White patients with childhood-onset kidney failure is unexplored. METHODS We analyzed 30-year cohort data of children beginning RRT before 18 years of age between January 1980 and December 2017 (n=28,337) in the US Renal Data System. Cox regression identified transplant factors associated with survival by race. The survival mediational g-formula estimated the excess mortality among Black patients that could be eliminated if an intervention equalized their time with a transplant to that of White patients. RESULTS Black children comprised 24% of the cohort and their crude 30-year survival was 39% compared with 57% for White children (log rank P<0.001). Black children had 45% higher risk of death (adjusted hazard ratio [aHR], 1.45; 95% confidence interval [95% CI], 1.36 to 1.54), 31% lower incidence of first transplant (aHR, 0.69; 95% CI, 0.67 to 0.72), and 39% lower incidence of second transplant (aHR, 0.61; 95% CI, 0.57 to 0.65). Children and young adults are likely to require multiple transplants, yet even after their first transplant, Black patients had 11% fewer total transplants (adjusted incidence rate ratio [aIRR], 0.89; 95% CI, 0.86 to 0.92). In Black patients, grafts failed earlier after first and second transplants. Overall, Black patients spent 24% less of their RRT time with a transplant than did White patients (aIRR, 0.76; 95% CI, 0.74 to 0.78). Transplantation compared with dialysis strongly protected against death (aHR, 0.28; 95% CI, 0.16 to 0.48) by time-varying analysis. Mediation analyses estimated that equalizing transplant duration could prevent 35% (P<0.001) of excess deaths in Black patients. CONCLUSIONS Equalizing time with a functioning transplant for Black patients may equalize survival of childhood-onset ESKD with White patients.
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Affiliation(s)
- Adan Z. Becerra
- Department of Public Health Sciences, Social and Scientific Systems, Silver Spring, Maryland
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Kevin E. Chan
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Paul W. Eggers
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Jenna Norton
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Paul L. Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Ivonne H. Schulman
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Susan R. Mendley
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
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25
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The Kidney Transplant Equity Index: Improving Racial and Ethnic Minority Access to Transplantation. Ann Surg 2022; 276:420-429. [PMID: 35762615 DOI: 10.1097/sla.0000000000005549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To develop a scalable metric which quantifies kidney transplant (KT) centers' performance providing equitable access to KT for minority patients, based on the individualized pre-listing prevalence of End-Stage Renal Disease (ESRD). SUMMARY BACKGROUND DATA Racial and ethnic disparities for access to transplant in patients with ESRD are well described; however, variation in care among KT centers remains unknown. Furthermore, no mechanism exists that quantifies how well a KT center provides equitable access to KT for minority patients with ESRD. METHODS From 2013-2018, custom datasets from the United States Renal Data System and United Network for Organ Sharing were merged to calculate the Kidney Transplant Equity Index (KTEI), defined as: the number of minority patients transplanted at a center relative to the prevalence of minority patients with ESRD in each center's health service area. Markers of socioeconomic status (SES) and recipient outcomes were compared between high and low KTEI centers. RESULTS 249 transplant centers performed 111,959 KTs relative to 475,914 non-transplanted patients with ESRD. High KTEI centers performed more KTs for Black (105.5 vs. 24, P<0.001), Hispanic (55.5 vs. 7, P<0.001), and American Indian (1.0 vs. 0.0, P<0.001) patients than low KTEI centers. In addition, high KTEI centers transplanted more patients with higher unemployment (52 vs. 44, P<0.001), worse social deprivation (53 vs. 46, P<0.001), and lower educational attainment (52 vs. 43, P<0.001). While providing increased access to transplant for minority and low SES populations, high KTEI centers had improved patient survival (HR: 0.86, 95% CI: 0.77-0.95). CONCLUSIONS The KTEI is the first metric to quantify minority access to KT incorporating the pre-listing ESRD prevalence individualized to transplant centers. KTEIs uncover significant national variation in transplant practices and identify highly equitable centers. This novel metric should be used to disseminate best practices for minority and low socioeconomic patients with ESRD.
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26
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Hippen BE, Axelrod DA, Maher K, Li R, Kumar D, Caliskan Y, Alhamad T, Schnitzler M, Lentine KL. Survey of current transplant center practices regarding COVID-19 vaccine mandates in the United States. Am J Transplant 2022; 22:1705-1713. [PMID: 35143100 PMCID: PMC9111251 DOI: 10.1111/ajt.16995] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/04/2022] [Accepted: 02/04/2022] [Indexed: 01/25/2023]
Abstract
An electronic survey canvassing current policies of transplant centers regarding a COVID-19 vaccine mandate for transplant candidates and living donors was distributed to clinicians at US solid organ transplant centers performing transplants from October 14, 2021-November 15, 2021. Responses were received from staff at 141 unique transplant centers. These respondents represented 56.4% of US transplant centers, and responding centers performed 78.5% of kidney transplants and 82.4% of liver transplants in the year prior to survey administration. Only 35.7% of centers reported implementing a vaccine mandate, while 60.7% reported that vaccination was not required. A minority (42%) of responding centers with a vaccine mandate for transplant candidates also mandated vaccination for living organ donors. Centers with a vaccine mandate most frequently cited clinical evidence supporting the efficacy of pre-transplant vaccination (82%) and stewardship obligations to ensure organs were transplanted into the lowest risk patients (64%). Centers without a vaccine mandate cited a variety of reasons including administrative, equity, and legal considerations for their decision. Transplant centers in the United States exhibit significant heterogeneity in COVID-19 vaccination mandate policies for transplant candidates. While all centers encourage vaccination, most centers have not mandated COVID-19 vaccination for candidates and living donors, citing administrative opposition, legal prohibitions, and concern about equity in access to transplants.
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Affiliation(s)
- Benjamin E. Hippen
- Fresenius Medical Care, Charlotte, North Carolina,Correspondence Benjamin E. Hippen, 729 East Worthington Avenue, Charlotte, NC 28203, USA.
| | | | - Kennan Maher
- Saint Louis University Transplant Center, St. Louis, Missouri
| | - Ruixin Li
- Saint Louis University Transplant Center, St. Louis, Missouri
| | | | - Yasar Caliskan
- Saint Louis University Transplant Center, St. Louis, Missouri
| | | | - Mark Schnitzler
- Saint Louis University Transplant Center, St. Louis, Missouri
| | - Krista L. Lentine
- Saint Louis University Transplant Center, St. Louis, Missouri,Krista L. Lentine, Saint Louis University Transplant Center, 1201 S. Grand Blvd., St. Louis, MO, 63104, USA.
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27
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Ferri F, Milana M, Abbatecola A, Pintore A, Lenci I, Parisse S, Vitale A, Di Croce G, Mennini G, Lai Q, Rossi M, Angelico R, Tisone G, Anselmo A, Angelico M, Corradini SG. Electronic Outpatient Referral System for Liver Transplant Improves Appropriateness and Allows First Visit Triage. Clin Gastroenterol Hepatol 2022; 20:e1388-e1415. [PMID: 34648952 DOI: 10.1016/j.cgh.2021.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 09/07/2021] [Accepted: 10/05/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Missed or inappropriate referrals of potential candidates for liver transplantation (LT) are common and traditional referral methods (tRs) do not allow for efficient triage. We investigated the effects of a website developed for electronic outpatient referral to LT (eRW-LT) on these issues. METHODS We prospectively collected data on all consecutive outpatient referrals to 2 Italian LT centers from January 2015 to December 2019. In the second half of the study, starting from July 2017, referring physicians had the option of using eRW-LT, quickly obtaining the judgment on the appropriateness and urgency of the visit from a transplant hepatologist. RESULTS In the second half of the study, there were 99 eRW-LTs and 96 traditional referrals (new tRs), representing a 17.4% increase over the 161 traditional referrals (old tRs) of the first half. With eRW-LT, 11.1% of referrals were judged inappropriate online without booking a visit. Appropriateness, judged at the time of the first visit, was 59.6%, 56.2%, and 94.3% with old tRs, new tRs, and eRW-LT, respectively. Considering the appropriate visits, the median waiting time in days between referral date and first visit appointment was significantly shorter for urgent visits referred with eRW-LT (5.0; 95% CI, 4.8-9.3) compared with nonurgent visits sent with the same system (17.0; 95% CI, 11.5-25.0; P < .0001), those referred with old tRs (14.0; 95% CI, 8.0-23.0; P < .001) and with new tRs (16.0; 95% CI, 10.0-23.0; P < .001). CONCLUSIONS eRW-LT allows an increase in the number of referrals for LT, ensuring effective triage and better appropriateness of visits.
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Affiliation(s)
- Flaminia Ferri
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy.
| | - Martina Milana
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | - Aurelio Abbatecola
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessandro Pintore
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Ilaria Lenci
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | - Simona Parisse
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | | | | | - Gianluca Mennini
- General Surgery and Organ Transplantation Unit, Department of Specialistic and Transplant Surgery "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, Department of Specialistic and Transplant Surgery "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Massimo Rossi
- General Surgery and Organ Transplantation Unit, Department of Specialistic and Transplant Surgery "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Roberta Angelico
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | - Giuseppe Tisone
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | - Alessandro Anselmo
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | - Mario Angelico
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
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28
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Past and Present Policy Efforts in Achieving Racial Equity in Kidney Transplantation. CURRENT TRANSPLANTATION REPORTS 2022; 9:114-118. [PMID: 35646512 PMCID: PMC9127821 DOI: 10.1007/s40472-022-00369-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2022] [Indexed: 11/01/2022]
Abstract
Purpose of Review Recent Findings Summary
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29
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Singh N, Li R, Alhamad T, Schnitzler MA, Mannon RB, Doshi MD, Woodside KJ, Hippen BE, Cooper M, Snyder J, Axelrod DA, Lentine KL. Exacerbation of Racial Disparities in Living Donor Kidney Transplantation During the COVID-19 Pandemic. KIDNEY360 2022; 3:1089-1094. [PMID: 35845323 PMCID: PMC9255874 DOI: 10.34067/kid.0008392021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/02/2022] [Indexed: 01/12/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic profoundly impacted transplant services, with a particularly strong impact on living donor kidney transplantation.The COVID-19 pandemic appears to have disproportionately impacted Black patients' access to living donor kidney transplantation.As the pandemic evolves through surges and vaccine acceptance disparities persist, ongoing attention to transplant disparities is needed.
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Affiliation(s)
- Neeraj Singh
- John C. McDonald Regional Transplant Center, Shreveport, Louisiana
| | - Ruixin Li
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri
| | | | | | | | | | | | | | | | - Jon Snyder
- Hennepin Healthcare Research Institute Minneapolis, Minnesota
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30
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DeBlasio RN, Myaskovsky L, DiMartini AF, Croswell E, Posluszny DM, Puttarajappa C, Switzer GE, Shapiro R, DeVito Dabbs AJ, Tevar AD, Hariharan S, Dew MA. The Combined Roles of Race/Ethnicity and Substance Use in Predicting Likelihood of Kidney Transplantation. Transplantation 2022; 106:e219-e233. [PMID: 35135973 PMCID: PMC9169160 DOI: 10.1097/tp.0000000000004054] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Racial/ethnic minorities face known disparities in likelihood of kidney transplantation. These disparities may be exacerbated when coupled with ongoing substance use, a factor also reducing likelihood of transplantation. We examined whether race/ethnicity in combination with ongoing substance use predicted incidence of transplantation. METHODS Patients were enrolled between March 2010 and October 2012 at the time of transplant evaluation. Substance use data were retrieved from transplant evaluations. Following descriptive analyses, the primary multivariable analyses evaluated whether, relative to the referent group (White patients with no substance use), racial/ethnic minority patients using any substances at the time of evaluation were less likely to receive transplants by the end of study follow-up (August 2020). RESULTS Among 1152 patients, 69% were non-Hispanic White, 23% non-Hispanic Black, and 8% Other racial/ethnic minorities. White, Black, and Other patients differed in percentages of current tobacco smoking (15%, 26%, and 18%, respectively; P = 0.002) and illicit substance use (3%, 8%, and 9%; P < 0.001) but not heavy alcohol consumption (2%, 4%, and 1%; P = 0.346). Black and Other minority patients using substances were each less likely to receive transplants than the referent group (hazard ratios ≤0.45, P ≤ 0.021). Neither White patients using substances nor racial/ethnic minority nonusers differed from the referent group in transplant rates. Additional analyses indicated that these effects reflected differences in waitlisting rates; once waitlisted, study groups did not differ in transplant rates. CONCLUSIONS The combination of minority race/ethnicity and substance use may lead to unique disparities in likelihood of transplantation. To facilitate equity, strategies should be considered to remove any barriers to referral for and receipt of substance use care in racial/ethnic minorities.
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Affiliation(s)
- Richelle N DeBlasio
- Department of Psychiatry, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Larissa Myaskovsky
- Department of Internal Medicine, Center for Healthcare Equity in Kidney Disease, University of New Mexico School of Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Andrea F DiMartini
- Department of Psychiatry, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Emilee Croswell
- Department of Psychiatry, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Donna M Posluszny
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
- UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA
| | | | - Galen E Switzer
- Department of Psychiatry, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Ron Shapiro
- Mount Sinai Recanati/Miller Transplantation Institute, Icahn School of Medicine, New York, NY
| | | | - Amit D Tevar
- Department of Surgery and Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
| | - Sundaram Hariharan
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
- Department of Surgery and Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
| | - Mary Amanda Dew
- Department of Psychiatry, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
- Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA
- Departments of Psychology, Epidemiology, and Biostatistics, University of Pittsburgh, Pittsburgh, PA
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31
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Kshirsagar AV, Weiner DE, Mendu ML, Liu F, Lew SQ, O’Neil TJ, Bieber SD, White DL, Zimmerman J, Mohan S. Keys to Driving Implementation of the New Kidney Care Models. Clin J Am Soc Nephrol 2022; 17:1082-1091. [PMID: 35289764 PMCID: PMC9269631 DOI: 10.2215/cjn.10880821] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Contemporary nephrology practice is heavily weighted toward in-center hemodialysis, reflective of decisions on infrastructure and personnel in response to decades of policy. The Advancing American Kidney Health initiative seeks to transform care for patients and providers. Under the initiative’s framework, the Center for Medicare and Medicaid Innovation has launched two new care models that align patient choice with provider incentives. The mandatory ESRD Treatment Choices model requires participation by all nephrology practices in designated Hospital Referral Regions, randomly selecting 30% of all Hospital Referral Regions across the United States for participation, with the remaining Hospital Referral Regions serving as controls. The voluntary Kidney Care Choices model offers alternative payment programs open to nephrology practices throughout the country. To help organize implementation of the models, we developed Driver Diagrams that serve as blueprints to identify structures, processes, and norms, and generate intervention concepts. We focused on two goals that are directly applicable to nephrology practices and central to the incentive structure of the ESRD Treatment Choices and Kidney Care Choices: (1) increasing utilization of home dialysis, and (2) increasing the number of kidney transplants. Several recurring themes became apparent with implementation. Multiple stakeholders from assorted backgrounds are needed. Communication with primary care providers will facilitate timely referrals, education, and comanagement. Nephrology providers (nephrologists, nursing, dialysis organizations, others) must lead implementation. Patient engagement at nearly every step will help achieve the aims of the models. Advocacy with federal and state regulatory agencies will be crucial to expanding home dialysis and transplantation access. Although the models hold promise to improve choices and outcomes for many patients, we must be vigilant that they not do reinforce existing disparities in health care or widen known racial, socioeconomic, or geographic gaps. The Advancing American Kidney Health initiative has the potential to usher in a new era of value-based care for nephrology.
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Affiliation(s)
- Abhijit V. Kshirsagar
- University of North Carolina Kidney Center and Division of Nephrology & Hypertension, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Quality Committee, American Society of Nephrology, Washington, DC
| | - Daniel E. Weiner
- Quality Committee, American Society of Nephrology, Washington, DC
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Mallika L. Mendu
- Quality Committee, American Society of Nephrology, Washington, DC
- Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Frank Liu
- Quality Committee, American Society of Nephrology, Washington, DC
- Division of Nephrology and Hypertension, Weill Cornell Medicine, Rogosin Institute, New York, New York
| | - Susie Q. Lew
- Quality Committee, American Society of Nephrology, Washington, DC
- Division of Renal Diseases and Hypertension, George Washington University, Washington, DC
| | - Terrence J. O’Neil
- Quality Committee, American Society of Nephrology, Washington, DC
- James Quillen Veterans Administration Medical Center, Johnson City, Tennessee
| | - Scott D. Bieber
- Quality Committee, American Society of Nephrology, Washington, DC
- Kootenai Health, Coeur d’Alene, Idaho
| | - David L. White
- Quality Committee, American Society of Nephrology, Washington, DC
- Policy and Government Affairs, American Society of Nephrology, Washington, DC
| | - Jonathan Zimmerman
- Center for Health Innovation, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Sumit Mohan
- Quality Committee, American Society of Nephrology, Washington, DC
- Division of Nephrology, Department of Medicine and Department of Epidemiology, Columbia University, New York, New York
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32
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Adler RR, Smith RN, Fowler KJ, Gates J, Jefferson NM, Adler JT, Patzer RE. Community Based Participatory Research (CBPR): An Underutilized Approach to Address Surgical Disparities. Ann Surg 2022; 275:496-499. [PMID: 34913903 DOI: 10.1097/sla.0000000000005329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Disparities are well-documented across the continuum of surgical care. Counteracting such disparities requires new multidisciplinary approaches that utilize the expertise of affected individuals, such as community-based participatory research (CBPR). CBPR is an approach to research that is anchored in equitable, sustainable community-academic partnerships, and has been shown to improve intervention implementation and outcomes. In this article, community stakeholders and researchers outline the principles and benefits of CBPR, examples of CBPR in trauma and transplant, and future directions for CBPR within surgery.
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Affiliation(s)
- Rachel R Adler
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Randi N Smith
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | | | | | | | - Joel T Adler
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, TX
| | - Rachel E Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
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A scoping review of inequities in access to organ transplant in the United States. Int J Equity Health 2022; 21:22. [PMID: 35151327 PMCID: PMC8841123 DOI: 10.1186/s12939-021-01616-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 12/24/2021] [Indexed: 02/06/2023] Open
Abstract
Background Organ transplant is the preferred treatment for end-stage organ disease, yet the majority of patients with end-stage organ disease are never placed on the transplant waiting list. Limited access to the transplant waiting list combined with the scarcity of the organ pool result in over 100,000 deaths annually in the United States. Patients face unique barriers to referral and acceptance for organ transplant based on social determinants of health, and patients from disenfranchised groups suffer from disproportionately lower rates of transplantation. Our objective was to review the literature describing disparities in access to organ transplantation based on social determinants of health to integrate the existing knowledge and guide future research. Methods We conducted a scoping review of the literature reporting disparities in access to heart, lung, liver, pancreas and kidney transplantation based on social determinants of health (race, income, education, geography, insurance status, health literacy and engagement). Included studies were categorized based on steps along the transplant care continuum: referral for transplant, transplant evaluation and selection, living donor identification/evaluation, and waitlist outcomes. Results Our search generated 16,643 studies, of which 227 were included in our final review. Of these, 34 focused on disparities in referral for transplantation among patients with chronic organ disease, 82 on transplant selection processes, 50 on living donors, and 61 on waitlist management. In total, 15 studies involved the thoracic organs (heart, lung), 209 involved the abdominal organs (kidney, liver, pancreas), and three involved multiple organs. Racial and ethnic minorities, women, and patients in lower socioeconomic status groups were less likely to be referred, evaluated, and added to the waiting list for organ transplant. The quality of the data describing these disparities across the transplant literature was variable and overwhelmingly focused on kidney transplant. Conclusions This review contextualizes the quality of the data, identifies seminal work by organ, and reports gaps in the literature where future research on disparities in organ transplantation should focus. Future work should investigate the association of social determinants of health with access to the organ transplant waiting list, with a focus on prospective analyses that assess interventions to improve health equity. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-021-01616-x.
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Hippen BE. Mandating COVID-19 vaccination prior to kidney transplantation in the United States: No solutions, only decisions. Am J Transplant 2022; 22:381-385. [PMID: 34780109 PMCID: PMC8652664 DOI: 10.1111/ajt.16891] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/02/2021] [Accepted: 11/13/2021] [Indexed: 02/06/2023]
Abstract
The question of whether transplant clinicians should mandate COVID-19 vaccination as a condition of transplant candidacy is complex. A vaccine mandate may be defensible on the grounds that transplant clinicians are obligated to ensure transplantation is conducted safely, and in a manner that entails the best use of a scarce public good. However, mandate proponents will inexorably predicate their arguments on contingent clinical judgments that meliorate rather than resolve core value disagreements. Vaccine mandates are conceivably defensible on narrow grounds, but may prove to be purchased at the expense of an attenuation of shared decision-making, proffering claims of risk reduction from a vaccine mandate beyond what the current evidence base supports, and unintentionally exacerbating durable inequities in access to transplantation.
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Affiliation(s)
- Benjamin E. Hippen
- Department of Transplant Medicine, Fresenius Medical Care, Charlotte, North Carolina,Correspondence Benjamin E. Hippen, Department of Transplant Medicine, Fresenius Medical Care, Charlotte, NC.
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Tummalapalli SL, Mendu ML. Value-Based Care and Kidney Disease: Emergence and Future Opportunities. Adv Chronic Kidney Dis 2022; 29:30-39. [PMID: 35690401 PMCID: PMC9199582 DOI: 10.1053/j.ackd.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/16/2021] [Accepted: 10/05/2021] [Indexed: 01/03/2023]
Abstract
The United States health care system has increasingly embraced value-based programs that reward improved outcomes and lower costs. Health care value, defined as quality per unit cost, was a major goal of the 2010 Patient Protection and Affordable Care Act amid high and rising US health care expenditures. Many early value-based programs were specifically designed for patients with end-stage renal disease (ESRD) and targeted toward dialysis facilities, including the ESRD Prospective Payment System, ESRD Quality Incentive Program, and ESRD Seamless Care Organizations. While a great deal of attention has been paid to these ESRD-focused programs, other value-based programs targeted toward hospitals and health systems may also affect the quality and costs of care for a broader population of patients with kidney disease. Value-based care for kidney disease is increasingly relevant in light of the Advancing American Kidney Health initiative, which introduces new value-based payment models: the mandatory ESRD Treatment Choices Model in 2021 and voluntary Kidney Care Choices Model in 2022. In this review article, we summarize the emergence and impact of value-based programs on the quality and costs of kidney care, with a focus on federal programs. Key opportunities in value-based kidney care include shifting the focus toward chronic kidney disease, enhancing population health management capabilities, improving quality measurement, and leveraging programs to advance health equity.
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Affiliation(s)
- Sri Lekha Tummalapalli
- Division of Healthcare Delivery Science & Innovation, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY,The Rogosin Institute, New York, NY
| | - Mallika L. Mendu
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA,Center for Population Health, Mass General Brigham, Boston, MA
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Godwin M. Nephrology Policy: Kidney Transplantation. Adv Chronic Kidney Dis 2022; 29:59-64. [PMID: 35690406 DOI: 10.1053/j.ackd.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Kidney transplant policy has not historically been considered a domain of nephrology policy; despite that, the US transplant system is marked by missed opportunities that prevent patients from accessing a kidney transplant. Policymakers in the federal government are focused on growing the inadequate supply of kidneys, especially on increasing procurement of deceased donor organs, and reducing kidney discards. There are many more challenges in transplantation that require the attention of experts in nephrology policy, whether in the Administration, Congress, advocacy organizations, or clinical practice. Thoughtful policy solutions are needed to improve transplant equity, balance competing patient desires, increase living donation, develop and implement measures of transplant center performance, and create an infrastructure for the long-term management of transplant recipients.
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Desai A, Sodhi RK, Akkina S. Kidney transplant outcomes in minority populations: can we close the gap? Curr Opin Organ Transplant 2021; 26:531-535. [PMID: 34375318 DOI: 10.1097/mot.0000000000000910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Health disparity in minority populations has been increasingly recognized over the last decade. The COVID-19 pandemic sheds a bright light on this very issue impressing upon the need for more research regarding healthcare in disparate populations. Although kidney transplantation remains the treatment of choice for end-stage renal disease management and longevity of life, access to transplantation remains a critical barrier in minority populations. The literature on disparity in access abounds but remains limited with regards to posttransplantation outcomes. The purpose of this review is to draw attention to existing research and literature in posttransplant outcomes and highlight the overall knowledge gap that persists in postkidney transplant care among disparate populations. RECENT FINDINGS The current review focuses on important paradigm shifts in the determinants of outcomes in posttransplantation care in minority populations. It emphasizes a departure from immune mediated causes to more salient health inequities and socioeconomic factors contributing to patient and graft survival which require further investigation. SUMMARY Despite increased awareness of health disparity in minority populations, outcomes data postkidney transplantation remains sparse. Critical to the future of kidney transplantation and improved healthcare coordination in minority populations will be a deeper understanding of contributing socio-economic variables in disparate outcomes.
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Affiliation(s)
- Amishi Desai
- Department of Medicine, Loyola University Medical Center, Maywood, Illinois, USA
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Martins PN, Kim IK. Editorial: Disparities in transplantation access and outcomes: mind the gap! Curr Opin Organ Transplant 2021; 26:498-500. [PMID: 34402456 DOI: 10.1097/mot.0000000000000919] [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: 11/25/2022]
Abstract
Organ transplantation still remains a problem of supply and demand and presents multiple ethical challenges to our society. Despite numerous targeted interventions and policy reforms, women, underrepresented minorities and patients with low socioeconomic status (SES) continue to have unequal access to transplant. The purpose of this special edition is to highlight disparities in access to transplantation and posttransplant outcomes. Acknowledging that these disparities exist is the first step toward interventions aimed at mitigating this long-standing inequity. This issue provides 10 articles that give the background and summarize relevant literature describing these disparities and identify potential areas of intervention. Most of the data relates to the United States but may reflect patterns encounter in most societies. Each manuscript was written by leaders of international teams in the field of patient advocacy, public health or outcome research in transplantation.
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Affiliation(s)
- Paulo N Martins
- Dept of Surgery, Division of Transplantation, University of Massachusetts, Worcester, Massachusetts
| | - Irene K Kim
- Comprehensive Transplant Center, Cedars-Sinai, Los Angeles, California, USA
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Adler JT, Xiang L, Weissman JS, Rodrigue JR, Patzer RE, Waikar SS, Tsai TC. Association of Public Reporting of Medicare Dialysis Facility Quality Ratings With Access to Kidney Transplantation. JAMA Netw Open 2021; 4:e2126719. [PMID: 34559227 PMCID: PMC8463939 DOI: 10.1001/jamanetworkopen.2021.26719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Improving the quality of dialysis care and access to kidney transplantation for patients with end-stage kidney disease is a national clinical and policy priority. The role of dialysis facility quality in increasing access to kidney transplantation is not known. OBJECTIVE To determine whether patient, facility, and kidney transplant waitlisting characteristics are associated with variations in dialysis center quality. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study is an analysis of US Renal Data System data and Medicare Dialysis Facility Compare (DFC) data from 2013 to 2018. Participants included all adult (aged ≥18 years) patients in the US Renal Data System beginning long-term dialysis in the US from 2013 to 2017 with follow-up through the end of 2018. Patients with a prior kidney transplant and matched Medicare DFC star ratings to each annual cohort of recipients were excluded. Patients at facilities without a star rating in that year were also excluded. Data analysis was performed from January to April 2021. EXPOSURES Dialysis center quality, as defined by Medicare DFC star ratings. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of patients undergoing incident dialysis who were waitlisted within 1 year of dialysis initiation. Secondary outcomes were patient and facility characteristics. RESULTS Of 507 581 patients beginning long-term dialysis in the US from 2013 to 2017, 291 802 (57.4%) were male, 266 517 (52.5%) were White, and the median (interquartile range) age was 65 (55-75) years. Of 5869 dialysis facilities in 2017, 132 (2.2%) were 1-star, 436 (7.4%) were 2-star, 2047 (34.9%) were 3-star, 1660 (28.3%) were 4-star, and 1594 (27.2%) were 5-star. Higher-quality dialysis facilities were associated with 47% higher odds of transplant waitlisting (odds ratio [OR], 1.47; 95% CI, 1.39-1.57 for 5-star facilities vs 1-star facilities; P < .001). Black patients were less likely than White patients to be waitlisted for transplantation (OR, 0.74; 95% CI, 0.72-0.76). In addition, patients at for-profit (OR, 0.78; 95% CI, 0.74-0.81) and rural (OR, 0.63; 95%, CI 0.58-0.68) facilities were less likely to be waitlisted for transplantation compared with those at nonprofit and urban facilities, respectively. CONCLUSIONS AND RELEVANCE In this cohort study, patients at higher-quality dialysis facilities had higher odds than patients at lower-quality facilities of being waitlisted for kidney transplantation within 1 year. Waitlisting rates for kidney transplantation should be considered for integration into the current Centers for Medicare & Medicaid Services DFC star ratings to incentivize dialysis facility referral to transplant centers, inform patient choice, and drive quality improvement by increasing transplant waitlisting rates.
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Affiliation(s)
- Joel T. Adler
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Lingwei Xiang
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Joel S. Weissman
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - James R. Rodrigue
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Rachel E. Patzer
- Department of Surgery, Emory Medical School, Atlanta, Georgia
- Department of Medicine, Emory Medical School, Atlanta, Georgia
| | - Sushrut S. Waikar
- Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Thomas C. Tsai
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Schold JD, Huml AM, Poggio ED, Sedor JR, Husain SA, King KL, Mohan S. Patients with High Priority for Kidney Transplant Who Are Not Given Expedited Placement on the Transplant Waiting List Represent Lost Opportunities. J Am Soc Nephrol 2021; 32:1733-1746. [PMID: 34140398 PMCID: PMC8425662 DOI: 10.1681/asn.2020081146] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 03/08/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Kidney transplantation is associated with the best outcomes for most patients with ESKD. The national Kidney Allocation System prioritizes patients with Estimated Post-Transplant Survival (EPTS) scores in the top 20% for expedited access to optimal deceased donor kidneys. METHODS We studied adults aged ≥18 years in the United States Renal Data System with top 20% EPTS scores who had been preemptively waitlisted or initiated dialysis in 2015-2017. We evaluated time to waitlist placement, transplantation, and mortality with unadjusted and multivariable survival models. RESULTS Of 42,445 patients with top 20% EPTS scores (mean age, 38.0 years; 57% male; 59% White patients, and 31% Black patients), 7922 were preemptively waitlisted. Among 34,523 patients initiating dialysis, the 3-year cumulative waitlist placement incidence was 37%. Numerous factors independently associated with waitlisting included race, income, and having noncommercial insurance. For example, waitlisting was less likely for Black versus White patients, and for patients in the lowest-income neighborhoods versus those in the highest-income neighborhoods. Among patients initiating dialysis, 61% lost their top 20% EPTS status within 30 months versus 18% of patients who were preemptively listed. The 3-year incidence of deceased and living donor transplantation was 5% and 6%, respectively, for patients who initiated dialysis and 26% and 44%, respectively, for patients who were preemptively listed. CONCLUSIONS Many patients with ESKDqualifying with top 20% EPTS status are not placed on the transplant waiting list in a timely manner, with significant variation on the basis of demographic and social factors. Patients who are preemptively listed are more likely to receive benefits of top 20% EPTS status. Efforts to expedite care for qualifying candidates are needed, and automated transplant referral for patients with the best prognoses should be considered. PODCAST This article contains a podcast athttps://www.asn-online.org/media/podcast/JASN/2021_07_30_JASN2020081146.mp3.
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Affiliation(s)
- Jesse D. Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Anne M. Huml
- Department of Nephrology and Hyptertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Emilio D. Poggio
- Department of Nephrology and Hyptertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - John R. Sedor
- Department of Nephrology and Hyptertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio,Department Immunology and Inflammation, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Syed A. Husain
- Division of Nephrology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York,The Columbia University Renal Epidemiology Group, Columbia University, New York, New York
| | - Kristin L. King
- Division of Nephrology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York,The Columbia University Renal Epidemiology Group, Columbia University, New York, New York
| | - Sumit Mohan
- Division of Nephrology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York,The Columbia University Renal Epidemiology Group, Columbia University, New York, New York
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