Rachel E. Patzer

Neighborhood poverty and racial disparities in kidney transplant waitlisting.

Racial disparities persist in the United States renal transplantation process. Previous studies suggest that the distance between a patients 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.

Standing the test of time: Outcomes of a decade of prioritizing patients with hepatocellular carcinoma, results of the UNOS natural geographic experiment

Priority is given to patients with hepatocellular carcinoma (HCC) to receive liver transplants, potentially causing significant regional disparities in organ access and possibly outcomes in this population. Our aim was to assess these disparities by comparing outcomes in long waiting time regions (LWTR, regions 5 and 9) and short waiting time regions (SWTR regions 3 and 10) by analyzing the United Network for Organ Sharing (UNOS) database. We analyzed 6,160 HCC patients who received exception points in regions 3, 5, 9, and 10 from 2002 to 2012. Data from regions 5 and 9 were combined and compared to data from regions 3 and 10. Survival was studied in three patient cohorts: an intent‐to‐treat cohort, a posttransplant cohort, and a cohort examining overall survival in transplanted patients only (survival from listing to last posttransplant follow‐up). Multivariate analysis and log‐rank testing were used to analyze the data. Median time on the list in the LWTR was 7.6 months compared to 1.6 months for SWTR, with a significantly higher incidence of death on the waiting list in LWTR than in SWTR (8.4% versus 1.6%, P < 0.0001). Patients in the LWTR were more likely to receive loco‐regional therapy, to have T3 tumors at listing, and to receive expanded‐criteria donor (ECD) or donation after cardiac death (DCD) grafts than patients in the SWTR (P < 0.0001 for all). Survival was significantly better in the LWTR compared to the SWTR in all three cohorts (P < 0.0001 for all three survival points). Being listed/transplanted in an SWTR was an independent predictor of poor patient survival on multivariate analysis (P < 0.0001, hazard ratio = 1.545, 95% confidence interval 1.375‐1.736). Conclusion: This study provides evidence that expediting patients with HCC to transplant at too fast a rate may adversely affect patient outcomes. (Hepatology 2014;60:1956–1961)

Association of Race and Insurance Type with Delayed Assessment for Kidney Transplantation among Patients Initiating Dialysis in the United States

BACKGROUND AND OBJECTIVES The extent to which racial and socioeconomic disparities in access to kidney transplantation are related to not being assessed for transplant suitability before or shortly after the time of initiation of dialysis is not known. The aims of this study were to determine whether there were disparities based on race, ethnicity, or type of insurance in delayed assessment for transplantation and whether delayed assessment was associated with lower likelihood of waitlisting and kidney transplantation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This retrospective cohort study used data from the US Renal Data System and included 426,489 adult patients beginning dialysis in the United States between January 1, 2005 and September 30, 2009 without prior kidney transplant. RESULTS Overall, 12.5% of patients had reportedly not been assessed for transplantation. Patients without private insurance were more likely to be reported as not assessed (multivariable adjusted odds ratio=1.33, 95% confidence interval=1.28-1.40 for Medicaid), with a pronounced racial disparity but no ethnic disparity among patients aged 18 to <35 years (odds ratio=1.27, 95% confidence interval=1.13-1.43; P<0.001 for interaction with age). Not being assessed for transplant around the time of dialysis initiation was associated with lower likelihood of waitlisting in multivariable analysis (hazard ratio=0.59, 95% confidence interval=0.57-0.62 in the first year) and transplantation (hazard ratio=0.46, 95% confidence interval=0.41-0.51 in the first year), especially within the first 2 years. CONCLUSIONS Racial and insurance-related disparities in transplant assessment potentially delay transplantation, particularly among younger patients.

Racial Disparities in Access to Pediatric Kidney Transplantation Since Share 35

Share 35 was enacted in 2005 to shorten transplant wait times and provide high-quality donors to children with ESRD. To investigate the possible effect of this policy on racial disparities in access to pediatric transplantation, we analyzed data from the US Renal Data System before and after Share 35. Among 4766 pediatric patients with incident ESRD, the probability of receiving a deceased-donor kidney transplant increased 46% after Share 35, with Hispanics experiencing the greatest improvements (increases of 81% for Hispanics, 45% for blacks, and 37% for whites). On average, patients received a deceased-donor kidney transplant earlier after Share 35, but this finding varied by race: 63 days earlier for whites, 90 days earlier for blacks, and 201 days earlier for Hispanics. Furthermore, a shift from living- to deceased-donor sources occurred with Share 35 for all races, with a 25% reduction in living donors for whites compared with 48% and 46% reductions for Hispanics and blacks, respectively. In summary, Share 35 seems to have attenuated racial disparities in the time to and probability of children receiving a deceased-donor kidney transplant. These changes coincided with changes in the rates of living-donor sources, which vary by race. Future studies should explore how these changes may impact racial differences in long-term graft outcomes.

Impact of a Patient Education Program on Disparities in Kidney Transplant Evaluation

BACKGROUND AND OBJECTIVES In 2007, the Emory Transplant Center (ETC) kidney transplant program implemented a required educational session for ESRD patients referred for renal transplant evaluation to increase patient awareness and decrease loss to follow-up. The purpose of this study was to evaluate the association of the ETC education program on completion of the transplant evaluation process. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Incident, adult ESRD patients referred from 2005 to 2008 were included. Patient data were abstracted from medical records and linked with data from the United States Renal Data System. Evaluation completion was compared by pre- and posteducational intervention groups in binomial regression models accounting for temporal confounding. RESULTS A total of 1126 adult ESRD patients were examined in two transplant evaluation eras (75% pre- and 25% postintervention). One-year evaluation completion was higher in the post- versus preintervention group (80.4% versus 44.7%, P<0.0001). In adjusted analyses controlling for time trends, the adjusted probability of evaluation completion at 1 year was higher among the intervention versus nonintervention group (risk ratio=1.38, 95% confidence interval=1.12-1.71). The effect of the intervention was stronger among black patients and those patients living in poor neighborhoods (likelihood ratio test for interaction, P<0.05). CONCLUSIONS Standardizing transplant education may help reduce some of the racial and socioeconomic disparities observed in kidney transplantation.

Dialysis Facility and Network Factors Associated With Low Kidney Transplantation Rates Among United States Dialysis Facilities

Variability in transplant rates between different dialysis units has been noted, yet little is known about facility‐level factors associated with low standardized transplant ratios (STRs) across the United States End‐stage Renal Disease (ESRD) Network regions. We analyzed Centers for Medicare & Medicaid Services Dialysis Facility Report data from 2007 to 2010 to examine facility‐level factors associated with low STRs using multivariable mixed models. Among 4098 dialysis facilities treating 305 698 patients, there was wide variability in facility‐level STRs across the 18 ESRD Networks. Four‐year average STRs ranged from 0.69 (95% confidence interval [CI]: 0.64–0.73) in Network 6 (Southeastern Kidney Council) to 1.61 (95% CI: 1.47–1.76) in Network 1 (New England). Factors significantly associated with a lower STR (p < 0.0001) included for‐profit status, facilities with higher percentage black patients, patients with no health insurance and patients with diabetes. A greater number of facility staff, more transplant centers per 10 000 ESRD patients and a higher percentage of patients who were employed or utilized peritoneal dialysis were associated with higher STRs. The lowest performing dialysis facilities were in the Southeastern United States. Understanding the modifiable facility‐level factors associated with low transplant rates may inform interventions to improve access to transplantation.

Variation in Dialysis Facility Referral for Kidney Transplantation Among Patients With End-Stage Renal Disease in Georgia

IMPORTANCE Dialysis facilities in the United States are required to educate patients with end-stage renal disease about all treatment options, including kidney transplantation. Patients receiving dialysis typically require a referral for kidney transplant evaluation at a transplant center from a dialysis facility to start the transplantation process, but the proportion of patients referred for transplantation is unknown. OBJECTIVE To describe variation in dialysis facility-level referral for kidney transplant evaluation and factors associated with referral among patients initiating dialysis in Georgia, the US state with the lowest kidney transplantation rates. DESIGN, SETTING, AND PARTICIPANTS Examination of United States Renal Data System data from a cohort of 15,279 incident, adult (18-69 years) patients with end-stage renal disease from 308 Georgia dialysis facilities from January 2005 to September 2011, followed up through September 2012, linked to kidney transplant referral data collected from adult transplant centers in Georgia in the same period. MAIN OUTCOMES AND MEASURES Referral for kidney transplant evaluation within 1 year of starting dialysis at any of the 3 Georgia transplant centers was the primary outcome; placement on the deceased donor waiting list was also examined. RESULTS The median within-facility percentage of patients referred within 1 year of starting dialysis was 24.4% (interquartile range, 16.7%-33.3%) and varied from 0% to 75.0%. Facilities in the lowest tertile of referral (<19.2%) were more likely to treat patients living in high-poverty neighborhoods (absolute difference, 21.8% [95% CI, 14.1%-29.4%]), had a higher patient to social worker ratio (difference, 22.5 [95% CI, 9.7-35.2]), and were more likely nonprofit (difference, 17.6% [95% CI, 7.7%-27.4%]) compared with facilities in the highest tertile of referral (>31.3%). In multivariable, multilevel analyses, factors associated with lower referral for transplantation, such as older age, white race, and nonprofit facility status, were not always consistent with the factors associated with lower waitlisting. CONCLUSIONS AND RELEVANCE In Georgia overall, a limited proportion of patients treated with dialysis were referred for kidney transplant evaluation between 2005 and 2011, but there was substantial variability in referral among facilities. Variables associated with referral were not always associated with waitlisting, suggesting that different factors may account for disparities in referral.

Kidney Transplant Access in the Southeast: View From the Bottom

The Southeastern region of the United States has the highest burden of end‐stage renal disease (ESRD) but the lowest rates of kidney transplantation in the nation. There are many patient‐, dialysis facility–, ESRD Network– and health system–level barriers that contribute to this regional disparity. Compared to the rest of the nation, the Southeast has a larger population of African‐Americans and higher poverty, as well as more prevalent ESRD risk factors including hypertension, obesity and diabetes. Dialysis facilities—where ESRD patients receive the majority of their healthcare—play an important role in transplant access. Identifying characteristics of individual dialysis units with low rates of kidney transplantation, such as understaffing or for‐profit status, can help identify targets for quality improvement initiatives. Geographic differences across the country can identify opportunities to increase funding for healthcare resources in proportion to patient and disease burden. Focusing interventions among dialysis facilities with the lowest transplant rates within the Southeast, such as provider and patient education, has the potential to increase referrals for kidney transplantation, leading to higher rates of kidney transplants in this region. Referral for transplantation should be measured on a national level to monitor disparities in early access to transplantation. Transplant centers have an obligation to assist underserved populations in ensuring equity in access to services. Policies that improve access to care for patients, such as the Affordable Care Act and Medicaid expansion, are particularly important for Southern states and may alleviate geographic disparities.

Medication misuse, nonadherence, and clinical outcomes among liver transplant recipients

Medication nonadherence after liver transplantation (LT) is associated with adverse clinical outcomes such as graft rejection and graft loss. Few studies have examined nonadherence and its impact on clinical outcomes in LT. The study objectives were (1) to evaluate medication understanding (with treatment knowledge and demonstrated regimen use scores) and medication adherence or nonadherence to entire regimens among LT recipients and (2) to examine associations of these exposures with clinical outcomes. We conducted a 2‐site study of 105 recipients between 2011 and 2012 at 2 transplant centers in Chicago, IL and Atlanta, GA. Data were collected via detailed, in‐person interviews and medical record reviews. Study participants were middle‐aged and predominantly male; 15% of the sample had limited literacy. On average, patients were taking 11 medications [standard deviation (SD) = 4], and 39% had undergone a medication change within the last month. The average scores for the entire medication regimen were 86% (SD = 22%) for treatment knowledge and 78% (SD = 22%) for demonstrated regimen use. The mean score for self‐reported nonadherence to the entire regimen was 14% (SD = 20%), whereas 32% of the patients were nonadherent according to tacrolimus levels. In multivariate analyses, lower income, less time since transplantation, a higher number of medications, and limited literacy were inversely associated with treatment knowledge scores (all P < 0.05), whereas limited literacy was associated with nonadherence according to tacrolimus levels (P < 0.05). In multivariate models, higher scores for treatment knowledge [incidence rate ratio (IRR) = 0.85, 95% confidence interval (CI) = 0.74‐0.97] and demonstrated regimen use (IRR = 0.87, 95% confidence interval = 0.77‐0.98) were independently associated with 15% and 13% reductions in the number of posttransplant rehospitalizations, respectively. Inadequate treatment knowledge and improper regimen use may be significant determinants of unintentional nonadherence among LT recipients and are associated with adverse clinical outcomes. Liver Transpl 21:22‐28, 2015.

One Size Does Not Fit All—Regional Variation in the Impact of the Share 35 Liver Allocation Policy

Allocation policies for liver transplantation underwent significant changes in June 2013 with the introduction of Share 35. We aimed to examine the effect of Share 35 on regional variation in posttransplant outcomes. We examined two patient groups from the United Network for Organ Sharing dataset; a pre–Share 35 group composed of patients transplanted between June 17, 2012, and June 17, 2013 (n = 5523), and a post–Share group composed of patients transplanted between June 18, 2013, and June 18, 2014 (n = 5815). We used Kaplan–Meier and Cox multivariable analyses to compare survival. There were significant increases in allocation Model for End‐stage Liver Disease (MELD) scores, laboratory MELD scores, and proportions of patients in the intensive care unit and on mechanical, ventilated, or organ‐perfusion support at transplant post–Share 35. We also observed a significant increase in donor risk index in this group. We found no difference on a national level in survival between patients transplanted pre–Share 35 and post–Share 35 (p = 0.987). Regionally, however, posttransplantation survival was significantly worse in the post–Share 35 patients in regions 4 and 10 (p = 0.008 and p = 0.04), with no significant differences in the remaining regions. These results suggest that Share 35 has been associated with transplanting “sicker patients” with higher MELD scores, and although no difference in survival is observed on a national level, outcomes appear to be concerning in some regions.