Inequalities in Transplant Waiting List Activation across Italian Dialysis Centers

Abstract

Background: The demand for kidney transplant exceeds organ supply; therefore, understanding patient-related and contextual factors associated with waiting list activation is key in ensuring that organ allocation is efficient and equitable. We sought to assess whether inequalities in wait-listing probability exist across centers and evaluate correlates of wait-listing in Italy. Methods: We linked the MigliorDialisi dataset (1,238 patients enrolled in 54 Italian hemodialysis centers) to administrative data concerning the activity of each participating center and contextual information abstracted from the Italian Institute of Statistics. We modeled the odds of waiting list activation for patients on dialysis by the subjects' sociodemographic, biomedical and psychosocial factors along with center-related and contextual factors. Results: The crude enlistment rate was 26% (95% CI 9-54) distributed as follows: 21, 34 and 33% in northern, central, and southern Italy, respectively (p < 0.01). Older patients with poorer health conditions and lower expectations toward transplantation outcomes were less likely to be wait-listed in multilevel multivariable logistic regression. In the fully adjusted model there was not a statistically significant variation in wait-listing across northern, central, and southern regions. However, the variance explained by center-related factors accounted for 12% (p < 0.01) of total variability in enlistment likelihood (20% in patients >65 years, p < 0.01). Conclusions: Our results showed that inter-center variation exists after adjusting for case mix. Additionally, we identified individual modifiable factors associated with wait-listing inequalities.

Access to preemptive registration on the waiting list for renal transplantation: a hierarchical modeling approach

“…Furthermore, we did not evaluate the effect of the size of the renal unit which could have been an adjustment variable. Indeed, the center size has been associated with rate of registration in previous studies .…”

“…Furthermore, we did not evaluate the effect of the size of the renal unit which could have been an adjustment variable. Indeed, the center size has been associated with rate of registration in previous studies [10,12,24]. Geographical and center differences in listing and transplantation practice have been reported in adult patients receiving dialysis or not, mainly in the UK [10,15] and in the USA [7,16,17].…”

“…In our study, we found that the likelihood of preemptive placement on the waiting list was lower in case of socioeconomic deprivation but, because we did not have the data to elucidate this specific question, we were not able to identify the underlying causes. Further studies are needed to explore the hypothesis of the interplay of socioeconomic status, patients' preferences, providers' perceptions of deprived patients, and social support network with preemptive registration, which has previously been formulated to explain racial disparities in kidney transplantation . It is otherwise important to notice that deprivation did not account for the center effect which meant that deprivation did not contribute to variability in preemptive registration rates between renal units.…”

Effect of age and care organization on sources of variation in kidney transplant waiting list registration

“…19 In the United Kingdom or Italy, the renal unit itself has been used as a level of granularity. 1,2,6,20 In France, variability between regions has already been published. 3,21 In France, the region represents the administrative level of healthcare organization under a regional health agency.…”

Il trapianto renale da cadavere: valutazione di idoneità del donatore e del rene

“…Il problema del reperimento degli organi e delle lunghe liste d’attesa è ulteriormente sottovalutato nel nostro paese in presenza di una notevole dise-guaglianza tra i centri dialisi nel segnalare i potenziali candidati al trapianto. 2 Infatti, è difficile immaginare che soltanto 6,500 pazienti sui circa 47,000 in trattamento dialitico (14%) risulterebbero idonei al trapianto di rene.…”