Modifiable Patient Characteristics and Racial Disparities in Evaluation Completion and Living Donor Transplant

Abstract

SummaryBackground and objectives To reduce racial disparities in transplant, modifiable patient characteristics associated with completion of transplant evaluation and receipt of living donor kidney transplant must be identified.Design, setting, participants, & measurements From 2004 to 2007, 695 black and white patients were surveyed about 15 less-modifiable and 10 more-modifiable characteristics at evaluation onset; whether they had completed evaluation within 1 year and received living donor kidney transplants by 2010 was determined. Logistic regression and competing risks time-to-event analysis were conducted to determine the variables that predicted evaluation completion and living donor kidney transplant receipt.Results Not adjusting for covariates, blacks were less likely than whites to complete evaluation (26.2% versus 51.8%, P,0.001) and receive living donor kidney transplants (8.7% versus 21.9%, P,0.001). More-modifiable variables associated with completing evaluation included more willing to be on the waiting list (odds ratio=3.4, 95% confidence interval=2.1, 5.7), more willing to pursue living donor kidney transplant (odds ratio=2.7, 95% confidence interval=1.8, 4.0), having access to more transplant education resources (odds ratio=2.2, 95% confidence interval=1.5, 3.2), and having greater transplant knowledge (odds ratio=1.8, 95% confidence interval=1.2, 2.7). Patients who started evaluation more willing to pursue living donor kidney transplant (hazard ratio=4.3, 95% confidence interval=2.7, 6.8) and having greater transplant knowledge (hazard ratio=1.2, 95% confidence interval=1.1, 1.3) were more likely to receive living donor kidney transplants.Conclusions Because patients who began transplant evaluation with greater transplant knowledge and motivation were ultimately more successful at receiving transplants years later, behavioral and educational interventions may be very successful strategies to reduce or overcome racial disparities in transplant.

Assessing Transplant Education Practices in Dialysis Centers

“…Incident rate ratios and 95% confidence intervals were calculated using negative binomial regression. Multiple studies have shown that many dialysis patients have poor knowledge about transplants as a treatment option (7,45). This study provides preliminary evidence that variation in the quantity of educational practices occurring within dialysis centers is high and can affect the numbers of dialysis patients moving forward to be evaluated and listed for transplant.…”

“…Research confirms that kidney patients who begin transplant evaluation having received more comprehensive education from community nephrologists or within dialysis centers are more likely to complete transplant evaluation successfully (5), get on the transplant waiting list (21), and receive LDKTs (7,22). In this study, reports to CMS using CMS Form-2728 and selfreports by educators about transplant education practices generally occurring in each dialysis center indicate that at least 77% of new dialysis patients were receiving some kind of education about transplant.…”

“…Unfortunately, substantial barriers affect whether all patients receive transplant education in dialysis centers (6), with black patients, older patients, obese patients, uninsured patients, and Medicaid-insured patients less likely to receive education about transplant before presenting at a transplant center (7,8). Transplant educators in dialysis centers (predominantly nurses and dialysis social workers) themselves report having limited time and knowledge to successfully educate patients about transplantation (9), with educators at for-profit dialysis centers less likely to administer high-quality, more intensive transplant educational strategies (e.g., one-on-one discussions) compared with nonprofit centers (6).…”

Living Donor Kidney Transplantation

“…Compared with white patients, minority kidney patients are less likely to receive transplant education before presenting for evaluation and they often begin evaluation less knowledgeable or ready to pursue transplantation (23). Black, Hispanic, and Asian patients are also less likely to receive LDKTs than white patients.…”

What Else Can We Do to Ensure Transplant Equity for High-Risk Patients?

“…However, a greater number of navigator encounters per patient was associated with both starting and completing the evaluation and higher waitlisting rates. This may speak to the greater value of the navigator for patients who are more ready or motivated to pursue transplant (9).…”