The Interplay of Socioeconomic Status, Distance to Center, and Interdonor Service Area Travel on Kidney Transplant Access and Outcomes (original) (raw)
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Geographic Variability in Access to Primary Kidney Transplantation in the United States, 1996?2005
American Journal of Transplantation, 2007
It examines geographic differences and trends in access rates to kidney transplantation, in the component rates of wait-listing, and of living and deceased donor transplantation. Using data from Centers for Medicare and Medicaid Services and the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients, we studied 700 000+ patients under 75, who began chronic dialysis treatment, received their first living donor kidney transplant, or were placed on the waiting list pre-emptively. Relative rates of wait-listing and transplantation by State were calculated using Cox regression models, adjusted for patient demographics. There were geographic differences in access to the kidney waiting list and to a kidney transplant. Adjusted wait-list rates ranged from 37% lower to 64% higher than the national average. The living donor rate ranged from 57% lower to 166% higher, while the deceased donor transplant rate ranged from 60% lower to 150% higher than the national average. In general, States with higher waitlisting rates tended to have lower transplantation rates and States with lower wait-listing rates had higher transplant rates. Six States demonstrated both high wait-listing and deceased donor transplantation rates while six others, plus D.C. and Puerto Rico, were below the national average for both parameters.
JAMA, 2009
IDNEY TRANSPLANTATION IS A life-saving medical procedure for which the demand far exceeds the supply of the resource (ie, transplantable organs). Transplantation improves clinical outcomes compared with dialysis, 1,2 and it is generally accepted that access to transplantation among suitable candidates should not be influenced by characteristics such as age, sex, race, socioeconomic status, or residence location. 3 A recent study suggested that rural location of residence within the United States was associated with lower rates of solid organ transplantation compared with those living in urban areas. 4 This finding is consistent with other work showing that rural dwellers have reduced access to health services 5,6 and raises the possibility that current organ allocation schemes may discriminate against people living farther away from transplant centers. However, this study did not account for potential differences in the need for transplantation between rural and urban populations. In addition, although almost all remote communities are rural, some rural communities may be in close geographic proximity to a transplant center and thus rural location of residence may not necessarily represent a geographic barrier to transplantation. We examined the association between distance from the closest transplant center and time to placement on the kidney transplantation waiting list or time to kidney transplantation. Be
Residence location and likelihood of kidney transplantation
Canadian Medical Association Journal, 2006
K idney transplantation is a life-saving medical procedure for which the demand far exceeds the supply of transplantable organs. Traditionally, access to transplantation is rationed according to the anticipated benefit to individual patients compared with dialysis treatment. 1,2 This practice is generally accepted because, unlike most other scarce medical resources, access to transplantation cannot be enhanced simply by increased resource allocation. In contrast, access to transplantation among suitable candidates should not be influenced by characteristics such as age, sex, race, socioeconomic status or residence location. 3 Compared with other industrialized nations, Canada is characterized by its large size and relatively few transplant centres, which suggests that access to transplantation may be influenced by geographic considerations. We studied kidney transplantation from deceased donors as an example of a scarce medical resource that is rationed in Canada's public health care system, focusing on the relation between place of residence and access to transplantation. First, because kidneys are not shared between geographic regions, we hypothesized that there would be regional variations in the likelihood of transplantation. Second, because the mandatory medical evaluation before transplantation is only available in tertiary care centres, 4,5 we hypothesized that people residing further from the nearest transplant centre would be less likely than those living closer to undergo transplantation. Methods This study was approved by the ethics review board at the University of Alberta and was conducted on a random sample of data from the Canadian Organ Replacement Registry (CORR), 6,7 which collects patient-specific data annually from all Canadian dialysis centres. Using a 2-step process that ensured the privacy of subjects (see online Appendix 1, available at www.cmaj.ca/cgi/content/full/175/5/478/DC1), we received a randomly selected subject-level dataset from CORR, which included clinical and demographic data, geographic location and distance from transplant centre for 7034 patients (about 36% of all subjects initiating dialysis in Canada between Jan. 1, 1996, and Dec. 31, 2000). Kidneys from deceased donors are not shared nationally in Canada. Instead organs are shared within 7 regions that closely follow provincial boundaries: British Columbia (includes Yukon Territory), Alberta (includes Northwest Territories),
Trends in kidney transplantation rates and disparities
Journal of the National Medical Association
To examine the likelihood of transplantation and trends over time among persons with end-stage renal disease (ESRD) in Wisconsin. We examined the influence of patient- and community-level characteristics on the rate of kidney transplantation in Wisconsin among 22,387 patients diagnosed with ESRD between January 1, 1982 and October 30, 2005. We grouped patients by the year of ESRD onset in order to model the change in transplantation rates over time. After multivariate adjustment, all other racial groups were significantly less likely to be transplanted compared with whites, and the racial disparity increased over calendar time. Older patients were less likely to be transplanted in all periods. Higher community income and education level and a greater distance from patients' residence to the nearest dialysis center significantly increased the likelihood of transplantation. Males also had a significantly higher rate of transplantation than females. These results demonstrate a grow...
Clinical journal of the American Society of Nephrology : CJASN, 2014
The Statewide Sharing variance to the national kidney allocation policy allocates kidneys not used within the procuring donor service area (DSA), first within the state, before the kidneys are offered regionally and nationally. Tennessee and Florida implemented this variance. Known geographic differences exist between the 58 DSAs, in direct violation of the Final Rule stipulated by the US Department of Health and Human Services. This study examined the effect of Statewide Sharing on geographic allocation disparity over time between DSAs within Tennessee and Florida and compared them with geographic disparity between the DSAs within a state for all states with more than one DSA (California, New York, North Carolina, Ohio, Pennsylvania, Texas, and Wisconsin). A retrospective analysis from 1987 to 2009 was conducted using Organ Procurement and Transplant Network data. Five previously used indicators for geographic allocation disparity were applied: deceased-donor kidney transplant rate...
Disparities in access to kidney transplantation between donor service areas in Texas
American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons, 2014
We examined the current status of pronounced disparities in waiting times to kidney transplantation (KTx) within the state of Texas first documented more than a decade ago. The state's three, geographically contiguous donor service areas (DSAs) were compared for rates of deceased donor KTx within 3 years of listing as well as population base; waiting list size; number of dialysis patients; annual eligible deaths; number and size of acute care hospitals; organ procurement organization performance; correspondence between DSA of residence versus DSA of listing; and distribution of alternative local units (ALUs). The data show that significant inequities of access to KTx are persistent, localized to one of the state's three DSAs and disproportionately affect Hispanics as well as counties with lower median family incomes. Imbalances in determinants of supply and demand, discordance between DSAs of residence versus listing and ALU dispositions dating to the 1990s were identified a...
American Journal of Transplantation, 2010
The effect of demand for kidney transplantation, measured by end-stage renal disease (ESRD) incidence, on access to transplantation is unknown. Using data from the U.S. Census Bureau, Centers for Medicare & Medicaid Services (CMS) and the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients (OPTN/SRTR) from 2000 to 2008, we performed donation service area (DSA) and patientlevel regression analyses to assess the effect of ESRD incidence on access to the kidney waiting list and deceased donor kidney transplantation. In DSAs, ESRD incidence increased with greater density of high ESRD incidence racial groups (African Americans and Native Americans). Wait-list and transplant rates were relatively lower in high ESRD incidence DSAs, but wait-list rates were not drastically affected by ESRD incidence at the patient level. Compared to low ESRD areas, high ESRD areas were associated with lower adjusted transplant rates among all ESRD patients (RR 0.68, 95% CI 0.66-0.70). Patients living in medium and high ESRD areas had lower transplant rates from the waiting list compared to those in low ESRD areas (medium: RR 0.68, 95% CI 0.66-0.69; high: RR 0.63, 95% CI 0.61-0.65). Geographic variation in access to kidney transplant is in part mediated by local ESRD incidence, which has implications for allocation policy development.
Neighborhood Poverty and Racial Disparities in Kidney Transplant Waitlisting
Journal of the American Society of Nephrology, 2009
Racial disparities persist in the United States renal transplantation process. Previous studies suggest that the distance between a patient's residence and the transplant facility may associate with disparities in transplant waitlisting. We examined this possibility in a cohort study using data for incident, adult ESRD patients (1998 to 2002) from the ESRD Network 6, which includes Georgia, North Carolina, and South Carolina. We linked data with the United Network for Organ Sharing (UNOS) transplant registry through 2005 and with the 2000 U.S. Census geographic data. Of the 35,346 subjects included in the analysis, 12% were waitlisted, 57% were black, 50% were men, 20% were impoverished, 45% had diabetes as the primary etiology of ESRD, and 73% had two or more comorbidities. The median distance from patient residence to the nearest transplant center was 48 mi. After controlling for multiple covariates, distance from patient residence to transplant center did not predict placement on the transplant waitlist. In contrast, race, neighborhood poverty, gender, age, diabetes, hypertension, body mass index, albumin, and the use of erythropoietin at dialysis initiation was associated with waitlisting. As neighborhood poverty increased, the likelihood of waitlisting decreased for blacks compared with whites in each poverty category; in the poorest neighborhoods, blacks were 57% less likely to be waitlisted than whites. This study suggests that improving the allocation of kidneys may require a focus on poor communities.
Kidney Transplantation and the Intensity of Poverty in the Contiguous United States
Transplantation, 2014
Background. Geographic variation in kidney transplantation rates in the United States has been described previously but remains unexplained by age, race, sex, or socioeconomic status differences. Geographic variations in the concentration of poverty appear to impact end-stage renal disease care and potentially access to transplantation. Methods. We studied the impact of how spatial topography of poverty across geographical regions in the contiguous United States is associated with kidney transplantation in the 48 contiguous U.S. states. Results. We found considerable geographic variation in transplantation rates across the country that persisted across quartiles of county-level median household income and percentage minority population. Higher transplant rates were seen with increasing median household income and decreasing minority populations but were not influenced by education level. Transplantation rates in counties with poverty rates above the national average had low transplant rates, but these rates were influenced by the poverty level in the surrounding counties. Similarly, wealthy counties had higher transplant rates but were lowered in counties of relative wealth that were surrounded by less wealthy counties. Conclusions. Our results underline the geographical heterogeneity of kidney transplantation in the United States and identify regions of the country most likely to benefit from interventions that may reduce disparities in transplantation.
Pediatric nephrology (Berlin, Germany), 2015
Low socioeconomic status (SES) and geographic disparity have been associated with worse outcomes and poorer access to pre-emptive transplantation in the adult end-stage kidney disease (ESKD) population, but little is known about their impact in children with ESKD. The aim of our study was to determine whether access to pre-emptive transplantation and transplant outcomes differ according to SES and geographic remoteness in Australia. Using data from the Australia and New Zealand Dialysis and Transplant Registry (1993-2012), we compared access to pre-emptive transplantation, the risk of acute rejection and graft failure, based on SES and geographic remoteness among Australian children with ESKD (≤18 years), using adjusted logistic and Cox proportional hazard modelling. Of the 768 children who commenced renal replacement therapy, 389 (50.5 %) received living donor kidney transplants and 28.5 % of these (111/389) were pre-emptive. There was no significant association between SES quintil...