Excluding patients from transplant due to social support: Results from a national survey of transplant providers

Abstract

Social support is used to determine transplant eligibility despite lack of an evidence base and vague regulatory guidance. It is unknown how many patients are disqualified from transplantation due to inadequate support, and whether providers feel confident using these subjective criteria to determine eligibility. Transplant providers (n = 551) from 202 centers estimated that, on average, 9.6% (standard deviation = 9.4) of patients evaluated in the prior year were excluded due to inadequate support. This varied significantly by United Network for Organ Sharing region (7.6%-12.2%), and by center (21.7% among top quartile). Significantly more providers used social support in listing decisions than believed it ought to be used (86.3% vs 67.6%). Nearly 25% believed that using social support in listing determinations was unfair or were unsure; 67.3% felt it disproportionately impacted patients of low socioeconomic status. Overall, 42.4% were only somewhat or not at all confident using social support to determine transplant suitability. Compared to surgical/medical transplant providers, psychosocial providers had 2.13 greater odds of supporting the criteria (P = .03). Furthermore, 69.2% supported revised guidelines for use of social support in listing decisions. Social support criteria should be reconsidered in light of the limited evidence, potential for disparities, practice variation, low provider confidence, and desire for revised guidelines.

The structural conundrum of parolees and kidney transplantation

“…Understandably, all of these factors have the collective potential to undermine a parolee's eligibility for transplant due to poor performance on the psychosocial evaluation, which has long been considered an important part of a candidate's transplant eligibility evaluation. 9,14,15 Although increasingly questioned in terms of importance of social support in determining transplant eligibility, 16,17 social support remains one of the key components in the psychosocial assessment of transplant eligibility for all solid organ transplant programs. Ladin et al 16 highlight data from a national survey of transplant providers that shows significantly more providers at Transplant Centers relied on social support in listing decisions than believed it ought to be used (86.3% vs 67.6%).…”

Improved outcomes after live donor renal transplantation for septuagenarians

“…However, transplantation for the elderly is associated with decreased overall graft survival and decreased graft survival after rejection episodes . It is more costly compared to transplanting younger recipients and transplant centers' averse to risk may decide to eschew aggressive surgical interventions …”

“…6 It is more costly compared to transplanting younger recipients and transplant centers' averse to risk may decide to eschew aggressive surgical interventions. [7][8][9] Additionally, although short-and medium-term risks of the LD are small, long-term outcomes (particularly in older, obese, and hypertensive donors) are not clearly elucidated. 10 Last, the expectations after LD have traditionally been outstanding long-term graft survival.…”

Rethinking How We Promote and Support Transplantation Research

“…Certainly, further research would be valuable. However, researchers have already made some traction on the topics that Lieber and colleagues call for, including those related to patient selection and patient education . The Clinical Trials in Organ Transplantation program sponsored by the National Institutes of Health (NIH) also attests to the numerous studies on postsurgical management for transplant recipients…”