Geographic Disparities in Liver Availability: Accidents of Geography, or Consequences of Poor Social Policy?

Recently, a redistricting proposal intended to equalize Model for End-stage Liver Disease score at transplant recommended expanding liver sharing to mitigate geographic variation in liver transplantation. Yet, it is unclear whether variation in liver availability is arbitrary and a disparity requiring rectification or reflects differences in access to care. We evaluate the proposal's claim that organ supply is an "accident of geography" by examining the relationship between local organ supply and the uneven landscape of social determinants and policies that contribute to differential death rates across the United States. We show that higher mortality leading to greater availability of organs may in part result from disproportionate risks incurred at the local level. Disparities in public safety laws, health care infrastructure, and public funding may influence the risk of death and subsequent availability of deceased donors. These risk factors are disproportionately prevalent in regions with high organ supply. Policies calling for organ redistribution from high-supply to low-supply regions may exacerbate existing social and health inequalities by redistributing the single benefit (greater organ availability) of greater exposure to environmental and contextual risks (e.g. violent death, healthcare scarcity). Variation in liver availability may not be an "accident of geography" but rather a byproduct of disadvantage.

Between Scylla and Charybdis: charting an ethical course for research into financial incentives for living kidney donation

New approaches to address the kidney scarcity in the United States are urgently needed. The greatest potential source of kidneys is from living donors. Proposals to offer financial incentives to increase living kidney donation rates remain highly controversial. Despite repeated calls for a pilot study to assess the impact of financial compensation on living kidney donation rates, many fear that financial incentives will exploit vulnerable individuals and cast the field of transplantation in a negative public light, ultimately reducing donation rates. This paper provides an ethical justification for conducting a pilot study of a federally regulated approach to providing financial incentives to living kidney donors, with the goal of assessing donors' perceptions.

Translating health psychology into effective health communication: the american healthstyles audience segmentation project

This article presents a health lifestyle audience segmentation analysis based primarily on social cognitive theory. Two linked mail surveys were conducted among a representative group of US adults (N = 2967). Segmentation variables included data on five health behaviors (smoking, alcohol consumption, physical activity, nutrition and weight control), internal personal and social/ environmental variables associated with each of the health behaviors, as well as health value, sensation- seeking, life satisfaction and age. K-means classification analysis was employed; seven health lifestyles were identified. The majority of the health lifestyles are reliable, and as a whole, all demonstrate both discriminative, construct and predictive validity. The health-lifestyle audience segments are briefly profiled, and an argument is made that health- lifestyle segmentation, more than demographic or behavioral segmentation alone, can advance the goals of public health communication.

Disclosing recipient information to potential living donors: preferences of donors and recipients, before and after surgery

Consensus guidelines, while recommending that potential living donors should be given information that could impact their donation decision, are nonspecific about the types of information that should be disclosed. We surveyed potential (n = 36) and past (n = 45) living donors and transplant candidates (n = 45) and recipients (n = 45) about their preferences for sharing or knowing specific information about the recipient, how this information would impact decision-making, and who should be responsible for disclosing information. Potential donors were less likely than all others to feel that recipient information should be disclosed to potential donors. Donors and recipients felt most strongly about disclosing if the recipient lost a previously transplanted kidney due to medication nonadherence as well as the likelihood of 1- and 5-year graft survival. Most donors would be less likely to pursue donation if the recipient lost a previously transplanted kidney due to medication nonadherence or generally had problems with taking medications as prescribed. Transplant programs should consider how to best balance the potential donor's right to receive information that could reasonably be expected to affect their decision-making process with the recipient's right to privacy and confidentiality.

Understanding disparities in transplantation: do social networks provide the missing clue?

Although the National Organ Transplant Act calls for equity in access to transplantation, scarcity and racial disparities persist. To date, even the most comprehensive models have been unable to adequately explain these racial disparities, leaving policymakers unsure how best to intervene. Previous individual-level analyses, which have implicated risk factors such as race, financial status, cultural beliefs, unemployment, lack of commitment to surgery and lack of continuous access to care, overlook contextual and social network exposures. Social networks present a compelling way to examine cumulative risk clustered across individuals. Social networks have been shown to influence health outcomes and health behaviors through various pathways, including shared social capital, engaging in similar or group risky behaviors, diffusion of information and adopting or propagating social norms. Precursors to chronic kidney disease, including obesity, have been shown to spread through social networks. Social network analysis can reveal shared risks between potential donors and recipients in a given network, clarifying the likelihood of finding an appropriate match through either direct donation or paired exchanges. This paper presents a novel application of social network analysis to transplantation, illustrating implications for disparities and future clinical interventions.