Keren Ladin

Risk of Late-Life Depression Across 10 European Union Countries: Deconstructing the Education Effect

Objective: Assess influence of education and noneducation-based measures of socioeconomic status on depression, illuminating the cumulative and income-adjusted effects cross-nationally. Method: Cross-sectional study of 22,777 men and women (50 to 104 years) from 10 European countries. Individual-level data were collected from the Survey of Health, Ageing and Retirement in Europe (SHARE). Results: Educational attainment was a strong predictor of late-life depression across all countries. Depression rates ranged from 18.10% in Denmark to 36.84% in Spain, reflecting a North— South gradient. Odds of depression were approximately twice as high among adults with less than a high school education compared with those of greater educational background (p < .001). Inverse association between educational attainment and depression remained significant independent of all other sociodemographic variables. Discussion : Socioeconomic disparities in depression persist throughout later life. Variation in impact of education on depression cross-nationally illuminates need for future research into the protective effects of early-life education.

Framing Disparities Along the Continuum of Care From Chronic Kidney Disease to Transplantation: Barriers and Interventions

Research in renal transplantation continues to document scores of disparities affecting vulnerable populations at various stages along the transplantation process. Given that both biological and environmental determinants contribute significantly to variation, identifying factors underlying an unfairly biased distribution of the disease burden is crucial. Confounded definitions and gaps in understanding causal pathways impede effectiveness of interventions aimed at alleviating disparities. This article offers an operational definition of disparities in the context of a framework aimed at facilitating interventional research. Utilizing an original framework describing the entire continuum of the transplant process from diagnosis of chronic kidney disease through successful transplant, this article explores the case of racial disparities, illustrating key factors predicting and perpetuating disparities. Though gaps in current research leave us unable to identify which stages of the transplant pathway adversely affect most people, by identifying key risk factors across the continuum of care, this article highlights areas suited for targeted interventions and presents recommendations for improvement and future research.

Exploring the Relationship Between Absolute and Relative Position and Late-Life Depression: Evidence From 10 European Countries

PURPOSE Socioeconomic inequality has been associated with higher levels of morbidity and mortality. This study explores the role of absolute and relative deprivation in predicting late-life depression on both individual and country levels. DESIGN AND METHODS Country- and individual-level inequality indicators were used in multivariate logistic regression and in relative indexes of inequality. Data obtained from the Survey of Health, Ageing and Retirement in Europe (SHARE, Wave 1, Release 2) included 22,777 men and women (aged 50-104 years) from 10 European countries. Late-life depression was measured using the EURO-D scale and corresponding clinical cut point. Absolute deprivation was measured using gross domestic product and median household income at the country level and socioeconomic status at the individual level. Relative deprivation was measured by Gini coefficients at the country level and educational attainment at the individual level. RESULTS Rates of depression ranged from 18.10% in Denmark to 36.84% in Spain reflecting a clear north-south gradient. Measures of absolute and relative deprivation were significant in predicting depression at both country and individual levels. Findings suggest that the adverse impact of societal inequality cannot be overcome by increased individual-level or country-level income. Increases in individual-level income did not mitigate the effect of country-level relative deprivation. IMPLICATIONS Mental health disparities persist throughout later life whereby persons exposed to higher levels of country-level inequality suffer greater morbidity compared with those in countries with less inequality. Cross-national variation in the relationship between inequality and depression illuminates the need for further research.

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.

Mental Health of Aging Immigrants and Native-Born Men Across 11 European Countries

OBJECTIVES Though working-age immigrants exhibit lower mortality compared with those domestic-born immigrants, consequences of immigration for mental health remain unclear. We examine whether older immigrants exhibit a mental advantage and whether factors believed to underlie immigrant vulnerability explain disparities. METHOD The sample includes 12,247 noninstitutionalized men more than 50 years in 11 European countries. Multivariate logistic regression models estimated the impact of physical health, health behaviors, availability of social support, social participation, citizenship, time since immigration, socioeconomic status (SES), and employment on the mental health of immigrants. RESULTS Immigrants face 1.60 increased odds of depression despite a physical health advantage, evidenced by 0.74 lower odds of chronic illness. SES and availability of social support were predictive, though acculturation measures were not. Decomposition analysis revealed that only approximately 20% of the variation in depression rates between immigrants and native-born peers were explained by commonly cited risk factors. CONCLUSIONS Despite physical health advantages, older immigrants suffer substantially higher depression rates. Time since immigration does not appear to mitigate depressive symptoms.

Rationing Lung Transplants — Procedural Fairness in Allocation and Appeals

In two recent cases of pediatric candidates for lung transplants, emergency legal injunctions claimed that lung-allocation policy is arbitrary and capricious. Appeals to list children for adult organs have merit, but lawsuits exacerbate inequities and undercut public trust.

Rational Rationing or Discrimination: Balancing Equity and Efficiency Considerations in Kidney Allocation

After 6 years of deliberation, the Organ Procurement and Transplantation Network recently released a concept document proposing changes to the kidney allocation algorithm, sparking a heated debate about priority‐setting of scarce health resources and discrimination. Proponents of the proposal argue that it will result in an additional 15 223 life years following transplant annually for recipients, yet the benefit will not be equally distributed and will likely benefit younger patients. Critics argue that the new model will promote age discrimination and may lead to a further decrease in live kidney donation. If true, these concerns could undermine fairness and damage public trust in the organ allocation system. We address these objections and consider their merit, highlighting both benefits and shortcomings of the proposal. We argue that, despite weaknesses of the proposal and the importance of maintaining consistency in patient and provider expectations over time, the proposal represents a needed first step in balancing equity and efficiency.

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 donors right to receive information that could reasonably be expected to affect their decision‐making process with the recipients right to privacy and confidentiality.

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 proposals 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.

Rationing lung transplants.

To the Editor: In their Perspective article, Ladin and Hanto (Aug. 15 issue)1 misrepresent the lung-allocation policy of the Organ Procurement and Transplantation Network (OPTN) by stating that candidates younger than 12 years of age are restricted to receiving lungs from donors younger than 12 years of age. In fact, within each organ procurement organization (OPO), lungs from donors younger than 18 years of age must be made available to all pediatric patients before being made available to adults. Children younger than 12 years of age may receive lungs from adult donors if the lungs are declined by adolescents and adults.2 Ladin and Hanto ignore critical references. The decision to exclude children younger than 12 years of age from receiving allocation scores was based on careful data review3; it did not result from insufficient data. Cystic fibrosis is indeed “the most common diagnosis among pediatric candidates” — but not among children younger than 12 years of age. This is another reason why calculating an allocation score was difficult. Waiting time was retained as a criterion in this age group because of the diversity of diagnoses and limited information about the risk of death among these patients and the effect of these diagnoses on survival after transplantation. The authors propagate the misperception that there are too few pediatric donors of lung transplants for children. Each year, less than 10% of organ donors younger than 11 years of age provide lungs, as compared with more than 35% of adolescent organ donors (Table 1). Nearly 30% of lungs from donors younger than 12 years of age are transplanted into adults (unpublished data from the OPTN). Thus, the reduced likelihood of transplantation in children 6 to 11 years of age cannot be ascribed solely to donor availability.4 We believe it results from a combination of geography and conservative pediatric transplantation programs. Finally, most children younger than 12 years of age are too small to receive lobar lung transplants from adult donors. In contrast to lobar liver transplants, lungs must fit into the thorax.