L. Ebony Boulware

Race and Trust in the Health Care System

Objective. A legacy of racial discrimination in medical research and the health care system has been linked to a low level of trust in medical research and medical care among African Americans. While racial differences in trust in physicians have been demonstrated, little is known about racial variation in trust of health insurance plans and hospitals. For the present study, the authors analyzed responses to a cross-sectional telephone survey to assess the independent relationship of self-reported race (non-Hispanic black or non-Hispanic white) with trust in physicians, hospitals, and health insurance plans. Methods. Respondents ages 18–75 years were asked to rate their level of trust in physicians, health insurance plans, and hospitals. Items from the Medical Mistrust Index were used to assess fear and suspicion of hospitals. Results. Responses were analyzed for 49 (42%) non-Hispanic black and 69 (58%) non-Hispanic white respondents (N=118; 94% of total survey population). A majority of respondents trusted physicians (71%) and hospitals (70%), but fewer trusted their health insurance plans (28%). After adjustment for potential confounders, non-Hispanic black respondents were less likely to trust their physicians than non-Hispanic white respondents (adjusted absolute difference 37%; p=0.01) and more likely to trust their health insurance plans (adjusted absolute difference 28%; p=0.04). The difference in trust of hospitals (adjusted absolute difference 13%) was not statistically significant. Non-Hispanic black respondents were more likely than non-Hispanic white respondents to be concerned about personal privacy and the potential for harmful experimentation in hospitals. Conclusions. Patterns of trust in components of our health care system differ by race. Differences in trust may reflect divergent cultural experiences of blacks and whites as well as differences in expectations for care. Improved understanding of these factors is needed if efforts to enhance patient access to and satisfaction with care are to be effective.

Determinants of willingness to donate living related and cadaveric organs: Identifying opportunities for intervention

Background. Although low rates of cadaveric organ donation have been attributed to potential cadaveric donors’ concerns regarding their religious beliefs and mistrust of the health care system, it is unclear whether similar concerns are important to potential living related donors. It is also not known which factors might be most responsible for low rates of cadaveric and living related donation among the general public. Methods. We conducted a cross-sectional study of households in Maryland, using a standardized telephone questionnaire, to assess factors associated with willingness to donate cadaveric and living related organs. We compared factors (demographic, cultural, attitudinal, and clinical) related to willingness to donate cadaveric organs with factors related to willingness to donate living related organs. In multivariate analyses, we assessed the independent relation of factors to willingness to donate cadaveric and living related organs, and we assessed the relative importance of these factors in explaining variation in the general public’s willingness to donate. Results. Of 385 participants (84% of randomized homes), 254 (66%) were extremely willing to donate to a sibling but only 179 (47%) had designated themselves a cadaveric donor on their drivers’ licenses. In bivariate analysis, older age, comorbid conditions, mistrust in hospitals, and concerns about discrimination in hospitals were statistically significantly associated with less willingness to donate living related organs, although African-Americans, older age, lower education, lack of insurance, unemployment, comorbid conditions, and religion/spirituality were associated with less willingness to donate cadaveric organs. After adjusting for potential confounders, only mistrust in hospitals and concerns about discrimination remained strongly and independently associated with 50 to 60% less odds of willingness to donate living related organs [[relative odds [95% confidence intervals (CI)]: 0.4 (0.2–0.7) to 0.5 (0.3–1.0) and 0.4 (0.2–0.9), respectively]] although presence of dependents was associated with 70% higher odds of willingness to donate living related organs [relative odds (95% CI): 1.7 (1.0–3.0)]. In contrast, older age, employment status, religion/spirituality, and mistrust in hospitals were associated with 50 to 90% less odds of willingness to donate living related organs cadaveric organs [relative odds (95% CI): 0.3 (0.1–0.8), 0.4(0.2–0.8), 0.1 (0.1- 0.5) to 0.5 (0.2–0.9), and 0.3 (0.2–0.6), respectively]. Mistrust in hospitals and concerns about the surgical donation procedure contributed most to the variation in willingness to be a living related donor, although race contributed most to the variation in willingness to be a cadaveric donor. Conclusions. Many factors affect the general public’s willingness to donate organs, but their relative contribution is different for living related versus cadaveric donation. Efforts to improve organ donation rates should be directed toward factors that are most important in explaining the existing variation in willingness to donate.

Fatal and nonfatal hemorrhagic complications of living kidney donation

Objective:After anecdotal reports of severe hemorrhage from failure of surgical clips to sustain closure of renal artery stumps in live donor nephrectomies were received, this study was designed to identify specific surgical techniques that are associated with an increased risk of failure to control bleeding and might represent opportunities to improve patient safety. Background:Preventing complications for living kidney donors must be paramount in addressing end-stage renal failure through living kidney donation. Major hemorrhage from technical failure, albeit an infrequent occurrence, can cause significant, yet preventable, morbidity or death. Open and laparoscopic approaches to living kidney donation use several vascular control methods, some of which may be more prone to failure and life-endangering hemorrhage than others. Methods:To define hemorrhagic complications of living kidney donation, a survey was sent to all 893 surgeon-members of the American Society of Transplant Surgeons. Descriptive and bivariate analyses were used to ascertain study participant characteristics, most frequently used vascular control techniques, and incidence of events (death, transfusion, reexploration or conversion to open nephrectomy, or contralateral [remaining kidney] renal failure). Outcomes of hemorrhage and comments by respondents were sought as were data from other sources. Results:In 213 surveys returned (24%), 66 and 39 episodes of arterial and venous hemorrhage were reported, respectively. Among arterial control problems, 2 resulted in donor death and 2 resulted in renal failure; 19 episodes required transfusion. Open conversions in laparoscopic nephrectomy or late reoperations for hemorrhage were reported for 29 cases. Locking and standard clips applied to the renal artery were associated with the greatest risks. Conclusions:Significant hemorrhagic complications occur with living kidney donation in both open and laparoscopic approaches. Loss of arterial control jeopardizes donor life and health, especially when it occurs in the postoperative period. Vascular transfixion provides the best vascular control of major vessels.

Temporal Relation among Depression Symptoms, Cardiovascular Disease Events, and Mortality in End-Stage Renal Disease: Contribution of Reverse Causality

Temporal relationships among depression, medical comorbidity, and death or cardiovascular disease (CVD) events are complex. Clarifying temporal relationships may enhance current insight regarding the nature of the association of depression with poor outcomes. The temporal relation of depression symptoms (DS; score < or = 52 on five-item Mental Health Index) assessed at 6-mo intervals for 2 yr to CVD event, all-cause death, cardiovascular disease deaths, and non-cardiovascular disease deaths was studied in 917 incident dialysis patients. Cox regression models were used to assess whether the proximity of DS measurement and DS duration would change observed associations between DS and events. Whether increasing medical comorbidity was associated with worsening DS also was assessed. In time-varying models, DS were strongly associated with all-cause deaths, cardiovascular disease deaths, and CVD events (adjusted relative hazard [95% confidence interval]: 2.22 [1.36 to 3.60], 3.27 [1.57 to 6.81], and 1.68 [1.05 to 2.69], respectively). Persistent and current DS were associated with greater risks for all-cause death. Incorporating a 6-mo time lag between DS and outcomes attenuated risks for all-cause death, non-cardiovascular disease deaths, and CVD events. In a subgroup analysis, patients with worsening medical comorbidity (n = 32) during the first year of follow-up experienced a 2.42-point greater decline in mental health scores at 2 yr of follow-up compared with patients with no worsening in medical comorbidity (n = 123), but findings were not statistically significant. DS are strongly related to death and CVD events, with persistent/current DS most strongly associated with poor outcomes. Attenuated risks from time-lag analyses indicate a partial role for reverse causality, suggesting that medical comorbidity may precede DS.

An Evidence-Based Review of Patient-Centered Behavioral Interventions for Hypertension

INTRODUCTION While behavioral interventions may be viewed as important strategies to improve blood pressure (BP), an evidence-based review of studies evaluating these interventions may help to guide clinical practice. METHODS We employed systematic review and meta-analysis of the literature (1970-1999) to assess the independent and additive effects of three behavioral interventions on BP control (counseling, self-monitoring of BP, and structured training courses). RESULTS Of 232 articles assessing behavioral interventions, 15 (4072 subjects) evaluated the effectiveness of patient-centered counseling, patient self-monitoring of BP, and structured training courses. Pooled results revealed that counseling was favored over usual care (3.2 mmHg [95% CI, 1.2-5.3] improvement in diastolic blood pressure [DBP] and 11.1 mmHg [95% CI, 4.1-18.1] improvement in systolic blood pressure [SBP]) and training courses (10 mmHg improvement in DBP [95% CI, 4.8-15.6]). Counseling plus training was favored over counseling (4.7 mmHg improvement in SBP [95% CI, 1.2-8.2]) and afforded more subjects hypertension control (95% [95% CI, 87-99]) than those receiving counseling (51% [95% CI, 34-66]) or training alone (64% [95% CI, 48-77]). CONCLUSIONS Evidence suggests that counseling offers BP improvement over usual care, and that adding structured training courses to counseling may further improve BP. However, there is not enough evidence to conclude whether self-monitoring of BP or training courses alone offer consistent improvement in BP over counseling or usual care. The magnitude of BP reduction offered by counseling indicates this may be an important adjunct to pharmacologic therapy.

High-Normal Albuminuria and Risk of Heart Failure in the Community

BACKGROUND Albuminuria has been associated with cardiovascular risk, but the relationship of high-normal albuminuria to subsequent heart failure has not been well established. STUDY DESIGN Prospective observational study, the Atherosclerosis Risk in Communities (ARIC) Study. SETTING & PARTICIPANTS 10,975 individuals free from heart failure were followed up from the fourth ARIC Study visit (1996-1998) through January 2006. PREDICTOR Urinary albumin-creatinine ratio (UACR), analyzed continuously and categorically as optimal (<5 mg/g), intermediate-normal (5-9 mg/g), high-normal (10-29 mg/g), microalbuminuria (30-299 mg/g), and macroalbuminuria (≥300 mg/g). OUTCOMES & MEASUREMENTS Incident heart failure was defined as a heart failure-related hospitalization or death. Cox proportional hazard models were used to calculate the HR of heart failure after adjustment for age, race, sex, estimated glomerular filtration rate (eGFR), and other cardiovascular risk factors. RESULTS Individuals were followed up for a median of 8.3 years and experienced 344 heart failure events. Compared with normal UACR, albuminuria was associated with a progressively increased risk of heart failure from intermediate-normal (adjusted HR, 1.54; 95% CI, 1.12-2.11) and high-normal UACR (adjusted HR, 1.91; 95% CI, 1.38-2.66) to microalbuminuria (adjusted HR, 2.49; 95% CI, 1.77-3.50) and macroalbuminuria (adjusted HR, 3.47; 95% CI, 2.10-5.72). Results were similar in secondary analyses of participants censored at the time of coronary heart disease event and along a range of eGFRs. LIMITATIONS UACR was measured as a single random sample. CONCLUSIONS Albuminuria is associated with subsequent heart failure, even in individuals with few cardiovascular risk factors and UACR within the normal range. Our results suggest that the association between albuminuria and heart failure may not be mediated fully by ischemic heart disease or kidney disease, measured using eGFR.

Age and Comorbidities Are Effect Modifiers of Gender Disparities in Renal Transplantation

Women have less access to kidney transplantation than men, but the contributions of age and comorbidity to this disparity are largely unknown. We conducted a national cohort study of 563,197 patients with first-onset ESRD between 2000 and 2005. We used multivariate generalized linear models to evaluate both access to transplantation (ATT), defined as either registration for the deceased-donor waiting list or receiving a live-donor transplant, and survival benefit from transplantation, defined as the relative rate of survival after transplantation compared with the rate of survival on dialysis. We compared relative risks (RRs) between women and men, stratified by age categories and the presence of common comorbidities. Overall, women had 11% less ATT than men. When the model was stratified by age, 18- to 45-yr-old women had equivalent ATT to men (RR 1.01), but with increasing age, ATT for women declined dramatically, reaching a RR of 0.41 for those who were older than 75 yr, despite equivalent survival benefits from transplantation between men and women in all age subgroups. Furthermore, ATT for women with comorbidities was lower than that for men with the same comorbidities, again despite similar survival benefits from transplantation. This study suggests that there is no disparity in ATT for women in general but rather a marked disparity in ATT for older women and women with comorbidities. These disparities exist despite similar survival benefits from transplantation for men and women regardless of age or comorbidities.

The general public's concerns about clinical risk in live kidney donation

Difficulty in attracting live kidney donors may be related to fears regarding both the surgical procedure for kidney harvesting and future failure of the remaining kidney. We conducted a cross‐sectional study of households in Maryland to identify public disincentives to living related kidney donation. In multivariate analyses, we assessed the independent effects of several factors on willingness to donate a kidney to a sibling. We also assessed thresholds for factors above which persons would not donate a kidney. Of 385 participants, 66% were extremely willing to donate to a sibling. After adjustment, those who considered the length of a hospital stay, out‐of‐pocket expenses, size and appearance of a scar, the time it takes to get to the transplant center, and the donor risk of developing kidney failure very important had 50–60% less odds of being extremely willing to donate. Median acceptable levels for risk of complications, hospital stay, compensated and uncompensated time from work, time requiring pain medications, and out‐of‐pocket expenses were greater than levels from clinical evidence regarding both laparoscopic and open nephrectomy. Unrealistic concerns among the general public regarding live donation may serve as potential disincentives to donation. Efforts to educate the public regarding live donation might help assuage fears and attract those who may not otherwise donate.

Association of Race With Mortality and Cardiovascular Events in a Large Cohort of US Veterans.

Background— In the general population, blacks experience higher mortality than their white peers, attributed in part to their lower socioeconomic status, reduced access to care, and possibly intrinsic biological factors. Patients with kidney disease are a notable exception, among whom blacks experience lower mortality. It is unclear if similar differences affecting outcomes exist in patients with no kidney disease but with equal or similar access to health care. Methods and Results— We compared all-cause mortality, incident coronary heart disease, and incident ischemic stroke using multivariable-adjusted Cox models in a nationwide cohort of 547 441 black and 2 525 525 white patients with baseline estimated glomerular filtration rate ≥60 mL·min−1·1.73 m−2 receiving care from the US Veterans Health Administration. In parallel analyses, we compared outcomes in black versus white individuals in the National Health and Nutrition Examination Survey (NHANES) 1999 to 2004. After multivariable adjustments in veterans, black race was associated with 24% lower all-cause mortality (adjusted hazard ratio, 0.76; 95% confidence interval, 0.75–0.77; P<0.001) and 37% lower incidence of coronary heart disease (adjusted hazard ratio, 0.63; 95% confidence interval, 0.62–0.65; P<0.001) but a similar incidence of ischemic stroke (adjusted hazard ratio, 0.99; 95% confidence interval, 0.97–1.01; P=0.3). Black race was associated with a 42% higher adjusted mortality among individuals with estimated glomerular filtration rate ≥60 mL·min−1·1.73 m−2 in NHANES (adjusted hazard ratio, 1.42; 95% confidence interval, 1.09–1.87). Conclusions— Black veterans with normal estimated glomerular filtration rate and equal access to healthcare have lower all-cause mortality and incidence of coronary heart disease and a similar incidence of ischemic stroke. These associations are in contrast to the higher mortality experienced by black individuals in the general US population.

Understanding and Overcoming Barriers to Living Kidney Donation Among Racial and Ethnic Minorities in the United States

In the United States, racial-ethnic minorities experience disproportionately high rates of ESRD, but they are substantially less likely to receive living donor kidney transplants (LDKT) compared with their majority counterparts. Minorities may encounter barriers to LDKT at several steps along the path to receiving it, including consideration, pursuit, completion of LDKT, and the post-LDKT experience. These barriers operate at different levels related to potential recipients and donors, health care providers, health system structures, and communities. In this review, we present a conceptual framework describing various barriers that minorities face along the path to receiving LDKT. We also highlight promising recent and current initiatives to address these barriers, as well as gaps in initiatives, which may guide future interventions to reduce racial-ethnic disparities in LDKT.