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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Courtney AE, Moorlock G, Van Assche K, Burnapp L, Mamode N, Lennerling A, Dor FJMF. Living Donor Kidney Transplantation in Older Individuals: An Ethical Legal and Psychological Aspects of Transplantation (ELPAT) View. Transpl Int 2023; 36:11139. [PMID: 37152615 PMCID: PMC10161899 DOI: 10.3389/ti.2023.11139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 04/12/2023] [Indexed: 05/09/2023]
Abstract
Living donor transplantation is the optimal treatment for suitable patients with end-stage kidney disease. There are particular advantages for older individuals in terms of elective surgery, timely transplantation, and early graft function. Yet, despite the superiority of living donor transplantation especially for this cohort, older patients are significantly less likely to access this treatment modality than younger age groups. However, given the changing population demographic in recent decades, there are increasing numbers of older but otherwise healthy individuals with kidney disease who could benefit from living donor transplantation. The complex reasons for this inequity of access are explored, including conscious and unconscious age-related bias by healthcare professionals, concerns relating to older living donors, ethical anxieties related to younger adults donating to aging patients, unwillingness of potential older recipients to consider living donation, and the relevant legislation. There is a legal and moral duty to consider the inequity of access to living donor transplantation, recognising both the potential disparity between chronological and physiological age in older patients, and benefits of this treatment for individuals as well as society.
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Affiliation(s)
- Aisling E. Courtney
- Regional Nephrology and Transplant Unit, Belfast City Hospital, Belfast, United Kingdom
- *Correspondence: Aisling E. Courtney,
| | - Greg Moorlock
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Kristof Van Assche
- Research Group Personal Rights and Property Rights, University of Antwerp, Antwerp, Belgium
| | - Lisa Burnapp
- NHS Blood and Transplant, Bristol, United Kingdom
| | - Nizam Mamode
- Department of Surgery, King’s College London, London, United Kingdom
| | - Annette Lennerling
- The Transplant Centre, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Frank J. M. F. Dor
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
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3
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Ramos KJ, Sykes J, Stanojevic S, Ma X, Ostrenga JS, Fink A, Quon BS, Marshall BC, Faro A, Petren K, Elbert A, Goss CH, Stephenson AL. Survival and Lung Transplant Outcomes for Individuals With Advanced Cystic Fibrosis Lung Disease Living in the United States and Canada: An Analysis of National Registries. Chest 2021; 160:843-853. [PMID: 33878343 DOI: 10.1016/j.chest.2021.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/02/2021] [Accepted: 04/02/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Understanding how health outcomes differ for patients with advanced cystic fibrosis (CF) lung disease living in the United States compared with Canada has health policy implications. RESEARCH QUESTION What are rates of lung transplant (LTx) and rates of death without LTx in the United States and Canada among individuals with FEV1 < 40% predicted? STUDY DESIGN AND METHODS This was a retrospective population-based cohort study, 2005 to 2016, using the US CF Foundation, United Network for Organ Sharing, and Canadian CF registries. Individuals with CF and at least two FEV1 measurements < 40% predicted within a 5-year period, age ≥ 6 years, without prior LTx were included. Multivariable competing risk regression for time to death without LTx (LTx as a competing risk) and time to LTx (death as a competing risk) was performed. RESULTS There were 5,899 patients (53% male) and 905 patients (54% male) with CF with FEV1 < 40% predicted living in the United States and Canada, respectively. Multivariable competing risk regression models identified an increased risk of death without LTx (hazard ratio [HR], 1.79; 95% CI, 1.52-2.1) and decreased LTx (HR, 0.66; 95% CI, 0.58-0.74) among individuals in the United States compared with Canada. More pronounced differences were seen in the patients in the United States with Medicaid/Medicare insurance compared with Canadians (multivariable HR for death without LTx, 2.24 [95% CI, 1.89-2.64]; multivariable HR for LTx, 0.54 [95% CI, 0.47-0.61]). Patients of nonwhite race were also disadvantaged (multivariable HR for death without LTx, 1.56 [95% CI, 1.32-1.84]; multivariable HR for LTx, 0.47 [95% CI, 0.36-0.62]). INTERPRETATION There are lower rates of LTx and an increased risk of death without LTx for US patients with CF with FEV1 < 40% predicted compared with Canadian patients. Findings are more striking among US patients with CF with Medicaid/Medicare health insurance, and nonwhite patients in both countries, raising concerns about underuse of LTx among vulnerable populations.
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Affiliation(s)
- Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA.
| | - Jenna Sykes
- Division of Respirology, St. Michael's Hospital, Toronto, ON, Canada
| | - Sanja Stanojevic
- Translational Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Xiayi Ma
- Division of Respirology, St. Michael's Hospital, Toronto, ON, Canada
| | | | - Aliza Fink
- Cystic Fibrosis Foundation, Bethesda, MD
| | - Bradley S Quon
- Division of Respirology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | | | | | | | - Christopher H Goss
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA
| | - Anne L Stephenson
- Division of Respirology, St. Michael's Hospital, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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4
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Preka E, Bonthuis M, Harambat J, Jager KJ, Groothoff JW, Baiko S, Bayazit AK, Boehm M, Cvetkovic M, Edvardsson VO, Fomina S, Heaf JG, Holtta T, Kis E, Kolvek G, Koster-Kamphuis L, Molchanova EA, Muňoz M, Neto G, Novljan G, Printza N, Sahpazova E, Sartz L, Sinha MD, Vidal E, Vondrak K, Vrillon I, Weber LT, Weitz M, Zagozdzon I, Stefanidis CJ, Bakkaloglu SA. Association between timing of dialysis initiation and clinical outcomes in the paediatric population: an ESPN/ERA-EDTA registry study. Nephrol Dial Transplant 2019; 34:1932-1940. [PMID: 31038179 DOI: 10.1093/ndt/gfz069] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 03/13/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There is no consensus regarding the timing of dialysis therapy initiation for end-stage kidney disease (ESKD) in children. As studies investigating the association between timing of dialysis initiation and clinical outcomes are lacking, we aimed to study this relationship in a cohort of European children who started maintenance dialysis treatment. METHODS We used data on 2963 children from 21 different countries included in the European Society of Pediatric Nephrology/European Renal Association-European Dialysis and Transplant Association Registry who started renal replacement therapy before 18 years of age between 2000 and 2014. We compared two groups according to the estimated glomerular filtration rate (eGFR) at start: eGFR ≥8 mL/min/1.73 m2 (early starters) and eGFR <8 mL/min/1.73 m2 (late starters). The primary outcomes were patient survival and access to transplantation. Secondary outcomes were growth and cardiovascular risk factors. Sensitivity analyses were performed to account for selection- and lead time-bias. RESULTS The median eGFR at the start of dialysis was 6.1 for late versus 10.5 mL/min/1.73 m2 for early starters. Early starters were older [median: 11.0, interquartile range (IQR): 5.7-14.5 versus 9.4, IQR: 2.6-14.1 years]. There were no differences observed between the two groups in mortality and access to transplantation at 1, 2 and 5 years of follow-up. One-year evolution of height standard deviation scores was similar among the groups, whereas hypertension was more prevalent among late initiators. Sensitivity analyses resulted in similar findings. CONCLUSIONS We found no evidence for a clinically relevant benefit of early start of dialysis in children with ESKD. Presence of cardiovascular risk factors, such as high blood pressure, should be taken into account when deciding to initiate or postpone dialysis in children with ESKD, as this affects the survival.
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Affiliation(s)
- Evgenia Preka
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marjolein Bonthuis
- ESPN/ERA-EDTA Registry, Amsterdam UMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Jerome Harambat
- Department of Pediatrics, Bordeaux University Hospital, Bordeaux, France
| | - Kitty J Jager
- ESPN/ERA-EDTA Registry, Amsterdam UMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Jaap W Groothoff
- Amsterdam UMC, University of Amsterdam, Department of Paediatric Nephrology, Emma Children's Academic Medical Center, Amsterdam, The Netherlands
| | - Sergey Baiko
- Department of Pediatrics, Belarusian State Medical University, Minsk, Belarus
| | - Aysun K Bayazit
- Department of Pediatric Nephrology, School of Medicine, Cukurova University, Adana, Turkey
| | - Michael Boehm
- Department of Pediatric Nephrology, University Children's Hospital, Vienna, Austria
| | - Mirjana Cvetkovic
- Nephrology Department, University Children's Hospital, Belgrade, Serbia
| | - Vidar O Edvardsson
- Children's Medical Center, Landspitali-The National University Hospital of Iceland, and Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Svitlana Fomina
- Department of Pediatric Nephrology, National Academy of Medical Sciences of Ukraine, Kiev, Ukraine
| | - James G Heaf
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Tuula Holtta
- Children's Hospital, University of Helsinki, Helsinki, Finland
| | - Eva Kis
- Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary
| | - Gabriel Kolvek
- Pediatric Department, Faculty of Medicine, Safarik University, Kosice, Slovakia
| | - Linda Koster-Kamphuis
- Department of Pediatric Nephrology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Elena A Molchanova
- Department of Kidney Transplantation, Russian Children's Clinical Hospital, Moscow, Russia
| | - Marina Muňoz
- Department of Pediatric Nephrology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Gisela Neto
- Paediatric Nephrology Unit, Hospital de Dona Estefânia, Lisbon, Portugal
| | - Gregor Novljan
- Department of Pediatric Nephrology, University Medical Center Ljubjana, Faculty of Medicine, University of Ljubjana, Slovenia
| | - Nikoleta Printza
- 1st Pediatric Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Lisa Sartz
- Department of Clinical Sciences, Pediatric Nephrology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Manish D Sinha
- Department of Paediatric Nephrology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Enrico Vidal
- Pediatric Nephrology, Dialysis and Transplantation Unit, Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Karel Vondrak
- Department of Pediatrics, University Hospital Motol, Prague, Czech Republic
| | - Isabelle Vrillon
- Pediatric Nephrology Department, Nancy University Hospital, Nancy, France
| | - Lutz T Weber
- Pediatric Nephrology, Childreńs and Adolescents` Hospital, University Hospital of Cologne, Cologne, Germany
| | - Marcus Weitz
- Pediatric Nephrology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ilona Zagozdzon
- Department of Pediatrics, Nephrology and Hypertension, Medical University of Gdansk, Gdansk, Poland
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Cantrelle C, Dorent R, Savoye E, Tuppin P, Lebreton G, Legeai C, Bastien O. Between-center disparities in access to heart transplantation in France: contribution of candidate and center factors - A comprehensive cohort study. Transpl Int 2017; 31:386-397. [PMID: 29130535 DOI: 10.1111/tri.13093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 09/20/2017] [Accepted: 11/08/2017] [Indexed: 11/29/2022]
Abstract
Transplantation represents the last option for patients with advanced heart failure. We assessed between-center disparities in access to heart transplantation in France 1 year after registration and evaluated the contribution of factors to these disparities. Adults (n = 2347) registered on the French national waiting list between January 1, 2010, and December 31, 2014, in the 23 transplant centers were included. Associations between candidate and transplant center characteristics and access to transplantation were assessed by proportional hazards frailty models. Candidate blood groups O and A, sensitization, and body mass index ≥30 kg/m2 were independently associated with lower access to transplantation, while female gender, severity of heart failure, and high serum bilirubin levels were independently associated with greater access to transplantation. Center factors significantly associated with access to transplantation were heart donation rate in the donation service area, proportion of high-urgency candidates among listed patients, and donor heart offer decline rate. Between-center variability in access to transplantation increased by 5% after adjustment for candidate factors and decreased by 57% after adjustment for center factors. After adjustment for candidate and center factors, five centers were still outside of normal variability. These findings will be taken into account in the future French heart allocation system.
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Affiliation(s)
| | | | | | - Philippe Tuppin
- Caisse Nationale d'Assurance Maladie des Travailleurs Salariés, Paris, France
| | - Guillaume Lebreton
- Service de Chirurgie Cardio-Vasculaire, Assistance Publique Hôpitaux de Paris, Hôpital de la Pitié Salpêtrière, Paris, France
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6
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Abstract
BACKGROUND Research focused on identifying vulnerable populations and revealing specific risk factors for barriers along the pathway from ESRD to kidney transplantation has been mostly descriptive and the causes of existing disparities remain unclear. However, several socio-economic factors that are associated with the access to and the outcome of the kidney transplantation have been identified. SUMMARY While the presence of racial, gender, and geographic disparities is noted, we were interested mostly to describe potential socio-economic factors associated with and possibly responsible for the presence of such disparities. In this review we focused on five factors: education level, employment status, income, presence of substance addiction or abuse, and marital status. We describe the new method to quantify patients' socio-economic status and identify the group of high risk in terms of the transplant outcome, easily calculated social adaptability index, previously associated with clinical outcome in several patient populations including those with kidney transplant. At the end, based on literature analyzed we offer potential interventions that potentially can be used in order to reduce the degree of disparities. CONCLUSION Based on review of literature socio-economic factors are associated with and possibly responsible for healthcare disparities. Social adaptability index allows quantifying the degree of socio-economic status and identifying the group of high risk for inferior transplant outcome.
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Affiliation(s)
- Tammy Hod
- Division of Nephrology and Center for Vascular Biology Research, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School , Boston , MA
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7
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Salter ML, McAdams-Demarco MA, Law A, Kamil RJ, Meoni LA, Jaar BG, Sozio SM, Kao WHL, Parekh RS, Segev DL. Age and sex disparities in discussions about kidney transplantation in adults undergoing dialysis. J Am Geriatr Soc 2014; 62:843-9. [PMID: 24801541 PMCID: PMC4024077 DOI: 10.1111/jgs.12801] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To explore whether disparities in age and sex in access to kidney transplantation (KT) originate at the time of prereferral discussions about KT. DESIGN Cross-sectional survey. SETTING Outpatient dialysis centers in Maryland (n = 26). PARTICIPANTS Individuals who had recently initiated hemodialysis treatment (N = 416). MEASUREMENTS Participants reported whether medical professionals (nephrologist, primary medical doctor, dialysis staff) and social group members (significant other, family member, friend) discussed KT with them and, when applicable, rated the tone of discussions. Relative risks were estimated using modified Poisson regression. RESULTS Participants aged 65 and older were much less likely than those who were younger to have had discussions with medical professionals (44.5% vs 74.8%, P < .001) or social group members (47.3% vs 63.1%, P = .005). Irrespective of sex and independent of race, health-related factors, and dialysis-related characteristics, older adults were more likely not to have had discussions with medical professionals (relative risk (RR) = 1.13, 95% confidence interval (CI) = 1.03-1.24, for each 5-year increase in age through 65; RR = 1.28, 95% CI = 1.14-1.42, for each 5-year increase in age beyond 65). Irrespective of age, women were more likely (RR = 1.45, 95% CI = 1.12-1.89) not to have had discussions with medical professionals. For each 5-year increase in age, men (RR = 1.04, 95% CI = 0.99-1.10) and women (RR = 1.17, 95% CI = 1.10-1.24) were more likely not to have discussions with social group members. Of those who had discussions with medical professionals or social group members, older participants described these discussions as less encouraging (all P < .01). CONCLUSION Older adults and women undergoing hemodialysis are less likely than younger adults and men to have discussions about KT as a treatment option, supporting a need for better clinical guidelines and education for these individuals, their social network, and their providers.
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Affiliation(s)
- Megan L Salter
- Department of Epidemiology, School of Public Health, Johns Hopkins University, Baltimore, Maryland; Center on Aging and Health, Johns Hopkins University, Baltimore, Maryland
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8
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Kutner NG, Johansen KL, Zhang R, Huang Y, Amaral S. Perspectives on the new kidney disease education benefit: early awareness, race and kidney transplant access in a USRDS study. Am J Transplant 2012; 12:1017-23. [PMID: 22226386 PMCID: PMC5844184 DOI: 10.1111/j.1600-6143.2011.03898.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Education services for Stage-IV chronic kidney disease patients were added in 2010 as a Part B covered benefit under the Medicare Improvements for Patients and Providers Act. Desired outcomes include early pursuit of kidney transplantation by more patients and reduction of racial disparities in access to transplantation. During 2005-2007, a United States Renal Data System (USRDS) special study surveyed 1123 patients in a national cohort who had recently started dialysis, identified themselves as black or white, and were reported by their physician as potentially eligible transplant candidates. Patients were asked if kidney transplantation had been discussed with them before they initiated renal replacement therapy, and survey responses were linked with subsequent wait listing and transplant events in USRDS registry files. Kaplan-Meier analyses showed a significant association between early transplant awareness and subsequent wait listing. Adjusted Cox models showed a significant race/early transplant awareness interaction, however, with the impact of early awareness on wait listing much stronger for whites. Ongoing support and education about kidney transplantation for patients after dialysis start could help to build on early education and foster greater quality improvement in patient outcomes.
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Affiliation(s)
- N. G. Kutner
- United States Renal Data System, Rehabilitation/Quality of Life Special Studies Center, Emory University, Atlanta, GA,Corresponding author: Nancy G. Kutner,
| | - K. L. Johansen
- United States Renal Data System, Rehabilitation/Quality of Life Special Studies Center, Emory University, Atlanta, GA,Nephrology Section, San Francisco VA Medical Center and Department of Medicine, University of California, San Francisco, CA
| | - R. Zhang
- United States Renal Data System, Rehabilitation/Quality of Life Special Studies Center, Emory University, Atlanta, GA
| | - Y. Huang
- United States Renal Data System, Rehabilitation/Quality of Life Special Studies Center, Emory University, Atlanta, GA
| | - S. Amaral
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA
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9
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Patzer RE, Amaral S, Klein M, Kutner N, Perryman JP, Gazmararian JA, McClellan WM. Racial disparities in pediatric access to kidney transplantation: does socioeconomic status play a role? Am J Transplant 2012; 12:369-78. [PMID: 22226039 PMCID: PMC3951009 DOI: 10.1111/j.1600-6143.2011.03888.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Racial disparities persist in access to renal transplantation in the United States, but the degree to which patient and neighborhood socioeconomic status (SES) impacts racial disparities in deceased donor renal transplantation access has not been examined in the pediatric and adolescent end-stage renal disease (ESRD) population. We examined the interplay of race and SES in a population-based cohort of all incident pediatric ESRD patients <21 years from the United States Renal Data System from 2000 to 2008, followed through September 2009. Of 8452 patients included, 30.8% were black, 27.6% white-Hispanic, 44.3% female and 28.0% lived in poor neighborhoods. A total of 63.4% of the study population was placed on the waiting list and 32.5% received a deceased donor transplant. Racial disparities persisted in transplant even after adjustment for SES, where minorities were less likely to receive a transplant compared to whites, and this disparity was more pronounced among patients 18-20 years. Disparities in access to the waiting list were mitigated in Hispanic patients with private health insurance. Our study suggests that racial disparities in transplant access worsen as pediatric patients transition into young adulthood, and that SES does not explain all of the racial differences in access to kidney transplantation.
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Affiliation(s)
- R. E. Patzer
- Department of Surgery, Emory Transplant Center, Emory University School of Medicine, Atlanta, GA,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Corresponding author: Rachel E. Patzer,
| | - S. Amaral
- Renal Division, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - M. Klein
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - N. Kutner
- Rehabilitation Medicine, Emory University, Atlanta, GA
| | | | - J. A. Gazmararian
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - W. M. McClellan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA,Renal Division, Emory University, Atlanta, GA
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10
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Patzer RE, Perryman JP, Schrager JD, Pastan S, Amaral S, Gazmararian JA, Klein M, Kutner N, McClellan WM. The role of race and poverty on steps to kidney transplantation in the Southeastern United States. Am J Transplant 2012; 12:358-68. [PMID: 22233181 PMCID: PMC3950902 DOI: 10.1111/j.1600-6143.2011.03927.x] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Racial disparities in access to renal transplantation exist, but the effects of race and socioeconomic status (SES) on early steps of renal transplantation have not been well explored. Adult patients referred for renal transplant evaluation at a single transplant center in the Southeastern United States from 2005 to 2007, followed through May 2010, were examined. Demographic and clinical data were obtained from patient's medical records and then linked with United States Renal Data System and American Community Survey Census data. Cox models examined the effect of race on referral, evaluation, waitlisting and organ receipt. Of 2291 patients, 64.9% were black, the mean age was 49.4 years and 33.6% lived in poor neighborhoods. Racial disparities were observed in access to referral, transplant evaluation, waitlisting and organ receipt. SES explained almost one-third of the lower rate of transplant among black versus white patients, but even after adjustment for demographic, clinical and SES factors, blacks had a 59% lower rate of transplant than whites (hazard ratio = 0.41; 95% confidence interval: 0.28-0.58). Results suggest that improving access to healthcare may reduce some, but not all, of the racial disparities in access to kidney transplantation.
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Affiliation(s)
- R. E. Patzer
- Emory Transplant Center, Emory University, Atlanta, GA,Emory Healthcare, Emory Transplant Center, Atlanta, GA,Corresponding author: Rachel E. Patzer,
| | | | | | - S. Pastan
- Emory Transplant Center, Emory University, Atlanta, GA,Emory University School of Medicine, Division of Nephrology, Atlanta, GA
| | - S. Amaral
- Children's Hospital of Philadelphia, Division of Nephrology, Philadelphia, PA
| | | | - M. Klein
- Emory Healthcare, Emory Transplant Center, Atlanta, GA
| | - N. Kutner
- Emory University, USRDS Rehabilitation/QoL Special Studies Center, Atlanta, GA
| | - W. M. McClellan
- Emory Healthcare, Emory Transplant Center, Atlanta, GA,Emory University School of Medicine, Division of Nephrology, Atlanta, GA
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11
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Abstract
We sought to characterize sex-based differences in access to deceased donor liver transplantation. Scientific Registry of Transplant Recipients data were used to analyze n = 78 998 adult candidates listed before (8/1997-2/2002) or after (2/2002-2/2007) implementation of Model for End-Stage Liver Disease (MELD)-based liver allocation. The primary outcome was deceased donor liver transplantation. Cox regression was used to estimate covariate-adjusted differences in transplant rates by sex. Females represented 38% of listed patients in the pre-MELD era and 35% in the MELD era. Females had significantly lower covariate-adjusted transplant rates in the pre-MELD era (by 9%; p < 0.0001) and in the MELD era (by 14%; p < 0.0001). In the MELD era, the disparity in transplant rate for females increased as waiting list mortality risk increased, particularly for MELD scores ≥15. Substantial geographic variation in sex-based differences in transplant rates was observed. Some areas of the United States had more than a 30% lower covariate-adjusted transplant rate for females compared to males in the MELD era. In conclusion, the disparity in liver transplant rates between females and males has increased in the MELD era. It is especially troubling that the disparity is magnified among patients with high MELD scores and in certain regions of the United States.
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Affiliation(s)
- A K Mathur
- Division of Transplantation, Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
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12
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Boyarsky BJ, Hall EC, Singer AL, Montgomery RA, Gebo KA, Segev DL. Estimating the potential pool of HIV-infected deceased organ donors in the United States. Am J Transplant 2011; 11:1209-17. [PMID: 21443677 PMCID: PMC3110583 DOI: 10.1111/j.1600-6143.2011.03506.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Human immunodeficiency virus (HIV) is no longer a contraindication to transplantation. For HIV-infected patients, HIV-infected deceased donors (HIVDD) could attenuate the organ shortage and waitlist mortality. However, this practice would violate United States federal law. The goal of this study was to estimate the potential impact of legalizing transplantation of HIV-infected organs by quantifying the potential pool of HIVDD. Using Nationwide Inpatient Sample (NIS) data, HIV-infected deaths compatible with donation were enumerated. Using HIV Research Network (HIVRN) data, CD4 count, plasma HIV-1 RNA level, AIDS-defining illnesses and causes of death were examined in potential HIVDD. Using UNOS data, evaluated donors who later demonstrated unanticipated HIV infections were studied. From NIS, a yearly average of 534 (range: 481-652) potential HIVDD were identified, with 63 (range: 39-90) kidney-only, 221 (range: 182-255) liver-only and 250 (range: 182-342) multiorgan donors. From HIVRN, a yearly average of 494 (range: 441-533) potential HIVDD were identified. Additionally, a yearly average of 20 (range: 11-34) donors with unanticipated HIV infection were identified from UNOS. Deceased HIV-infected patients represent a potential of approximately 500-600 donors per year for HIV-infected transplant candidates. In the current era of HIV management, a legal ban on the use of these organs seems unwarranted and likely harmful.
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Affiliation(s)
- Brian J. Boyarsky
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Erin C. Hall
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, Department of Surgery, Georgetown University School of Medicine, Washington, DC
| | - Andrew L. Singer
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Kelly A. Gebo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, HIV Research Network
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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13
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Melancon JK, Kucirka LM, Boulware LE, Powe NR, Locke JE, Montgomery RA, Segev DL. Impact of Medicare coverage on disparities in access to simultaneous pancreas and kidney transplantation. Am J Transplant 2009; 9:2785-91. [PMID: 19845587 PMCID: PMC3644052 DOI: 10.1111/j.1600-6143.2009.02845.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In the setting of disparities in access to simultaneous pancreas and kidney transplantation (SPKT), Medicare coverage for this procedure was initiated July 1999. The impact of this change has not yet been studied. A national cohort of 22 190 type 1 diabetic candidates aged 18-55 for kidney transplantation (KT) alone or SPKT was analyzed. Before Medicare coverage, 57% of Caucasian, 36% of African American and 38% of Hispanic type 1 diabetics were registered for SPKT versus KT alone. After Medicare coverage, these proportions increased to 68%, 45% and 43%, respectively. The overall increase in SPKT registration rate was 27% (95% CI 1.16-1.38). As expected, the increase was more substantial in patients with Medicare primary insurance than those with private insurance (Relative Rate 1.18, 95% CI 1.09-1.28). However, racial disparities were unaffected by this policy change (African American vs. Caucasian: 0.97, 95% CI 0.87-1.09; Hispanic vs. Caucasian: 0.94, 95% CI 0.78-1.05). Even after Medicare coverage, African Americans and Hispanics had almost 30% lower SPKT registration rates than their Caucasian counterparts (95% CI 0.66-0.79 and 0.59-0.80, respectively). Medicare coverage for SPKT succeeded in increasing access for patients with Medicare, but did not affect the substantial racial disparities in access to this procedure.
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Affiliation(s)
- J. K. Melancon
- Department of Surgery, Georgetown University, Washington, DC,Corresponding author: Joseph Keith Melancon,
| | - L. M. Kucirka
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - L. E. Boulware
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - N. R. Powe
- Department of Medicine, University of California, San Francisco, CA
| | - J. E. Locke
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - R. A. Montgomery
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - D. L. Segev
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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14
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Bryce CL, Angus DC, Arnold RM, Chang CCH, Farrell MH, Manzarbeitia C, Marino IR, Roberts MS. Sociodemographic differences in early access to liver transplantation services. Am J Transplant 2009; 9:2092-101. [PMID: 19645706 PMCID: PMC2880404 DOI: 10.1111/j.1600-6143.2009.02737.x] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The question of whether health care inequities occur before patients with end-stage liver disease (ESLD) are waitlisted for transplantation has not previously been assessed. To determine the impact of gender, race and insurance on access to transplantation, we linked Pennsylvania sources of data regarding adult patients discharged from nongovernmental hospitals from 1994 to 2001. We followed the patients through 2003 and linked information to records from five centers responsible for 95% of liver transplants in Pennsylvania during this period. Using multinomial logistic regressions, we estimated probabilities that patients would undergo transplant evaluation, transplant waitlisting and transplantation itself. Of the 144,507 patients in the study, 4361 (3.0%) underwent transplant evaluation. Of those evaluated, 3071 (70.4%) were waitlisted. Of those waitlisted, 1537 (50.0%) received a transplant. Overall, 57,020 (39.5%) died during the study period. Patients were less likely to undergo evaluation, waitlisting and transplantation if they were women, black and lacked commercial insurance (p < 0.001 each). Differences were more pronounced for early stages (evaluation and listing) than for the transplantation stage (in which national oversight and review occur). For early management and treatment decisions of patients with ESLD to be better understood, more comprehensive data concerning referral and listing practices are needed.
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Affiliation(s)
- C. L. Bryce
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA,Section for Decision Sciences and Clinical Systems Modeling, University of Pittsburgh, Pittsburgh, PA,Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA,Corresponding author: Cindy L. Bryce,
| | - D. C. Angus
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Laboratory, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA,Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - R. M. Arnold
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - C.-C. H. Chang
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA,Section for Decision Sciences and Clinical Systems Modeling, University of Pittsburgh, Pittsburgh, PA,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - M. H. Farrell
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - C. Manzarbeitia
- (former) Chair, Division of Transplant Surgery, Einstein Medical Center and Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - I. R. Marino
- Department of Surgery, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA
| | - M. S. Roberts
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA,Section for Decision Sciences and Clinical Systems Modeling, University of Pittsburgh, Pittsburgh, PA,Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA,Department of Industrial Engineering, University of Pittsburgh, Pittsburgh, PA
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