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

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.

Chief Residency Selection in Internal Medicine: Who Is Left Out?

Little progress has been made in improving racial, gender, or intersectional diversity within academic internal medicine (IM). Chief Residency fulfills a unique opportunity to target diversity efforts; Chief Residents (CR) are integral in creating an inclusive environment and support system for IM trainees, and the position serves as a steppingstone for future leadership positions within academia. However, the CR selection process often lacks transparency and includes steps that are fraught with bias, thereby disadvantaging underrepresented minority groups from gaining important experience needed to climb the academic ladder. We describe a more standardized selection process that will improve recruitment and selection of more diverse CRs and ultimately improve the recruitment, retention, and promotion of more diverse faculty within academic internal medicine. Key recommendations include an open call for applications, the use of standardized and structured interviews, and the formation of a diverse selection committee to conduct a transparent selection process based on explicitly defined criteria.

A 36-Year-Old Moroccan Man Presenting with Widespread Papules and Pustules

Cutaneous manifestations of tuberculosis are uncommon, can be nonspecific, and may demonstrate a wide variety of morphologies, including ulcerative papules, verrucous plaques, or nodules. We report the case of a 36-year-old Moroccan man who presented with nearly 2 years of generalized folliculocentric pustules and nodules, night sweats, and weight loss. Workup revealed necrotic right axillary lymphadenopathy, multiple ill-defined hepatic lesions, and a positive interferon-γ release assay. These findings were most consistent with papulonecrotic tuberculosis.

Fostering Student-Faculty Partnerships for Continuous Curricular Improvement in Undergraduate Medical Education

PROBLEM

A number of medical schools have used curricular reform as an opportunity to formalize student involvement in medical education, but there are few published assessments of these programs. Formal evaluation of a program's acceptability and use is essential for determining its potential for sustainability and generalizability.

APPROACH

Harvard Medical School's Education Representatives (Ed Reps) program was created in 2015 to launch alongside a new curriculum. The program aimed to foster partnerships between faculty and students for continuous and real-time curricular improvement. Ed Reps, course directors, and core faculty met regularly to convey bidirectional feedback to optimize the learning environment in real time.

OUTCOMES

A survey to assess the program's impact was sent to students and faculty. The majority of students (202/222; 91.0%) reported Ed Reps had a positive impact on the curriculum. Among faculty, 35/37 (94.6%) reported making changes to their courses as a result of Ed Reps feedback, and 34/37 (91.9%) agreed the program had a positive impact on the learning environment. Qualitative feedback from students and faculty demonstrated a change in school culture, reflecting the primary goals of partnership and continuous quality improvement (CQI).

NEXT STEPS

This student-faculty partnership demonstrated high rates of awareness, use, and satisfaction among faculty and students, suggesting its potential for local sustainability and implementation at other schools seeking to formalize student engagement in CQI. Next steps include ensuring the feedback provided is representative of the student body and identifying new areas for student CQI input as the curriculum becomes more established.