A scoping review of inequities in access to organ transplant in the United States

Abstract

Background Organ transplant is the preferred treatment for end-stage organ disease, yet the majority of patients with end-stage organ disease are never placed on the transplant waiting list. Limited access to the transplant waiting list combined with the scarcity of the organ pool result in over 100,000 deaths annually in the United States. Patients face unique barriers to referral and acceptance for organ transplant based on social determinants of health, and patients from disenfranchised groups suffer from disproportionately lower rates of transplantation. Our objective was to review the literature describing disparities in access to organ transplantation based on social determinants of health to integrate the existing knowledge and guide future research. Methods We conducted a scoping review of the literature reporting disparities in access to heart, lung, liver, pancreas and kidney transplantation based on social determinants of health (race, income, education, geography, insurance status, health literacy and engagement). Included studies were categorized based on steps along the transplant care continuum: referral for transplant, transplant evaluation and selection, living donor identification/evaluation, and waitlist outcomes. Results Our search generated 16,643 studies, of which 227 were included in our final review. Of these, 34 focused on disparities in referral for transplantation among patients with chronic organ disease, 82 on transplant selection processes, 50 on living donors, and 61 on waitlist management. In total, 15 studies involved the thoracic organs (heart, lung), 209 involved the abdominal organs (kidney, liver, pancreas), and three involved multiple organs. Racial and ethnic minorities, women, and patients in lower socioeconomic status groups were less likely to be referred, evaluated, and added to the waiting list for organ transplant. The quality of the data describing these disparities across the transplant literature was variable and overwhelmingly focused on kidney transplant. Conclusions This review contextualizes the quality of the data, identifies seminal work by organ, and reports gaps in the literature where future research on disparities in organ transplantation should focus. Future work should investigate the association of social determinants of health with access to the organ transplant waiting list, with a focus on prospective analyses that assess interventions to improve health equity.

Association between social determinants of health and rates of liver transplantation in individuals with cirrhosis

“…To date, our knowledge on how SDOH and systematic racism influence the LT process is scare. [ 25 ] In our cohort, the majority of patients with ALD resided in the most vulnerable neighborhoods for income (27%), material resources (28%), and housing instability (30%), with ALD as the etiology of cirrhosis associated with the lowest subhazard of LT. Historically, LT programs in North America would not consider an individual eligible for wait‐listing before 6 months of alcohol abstinence.…”

EQUIP emergency: can interventions to reduce racism, discrimination and stigma in EDs improve outcomes?

“…Efforts to promote equity have been made at the national and international policy levels, and at the level of educating care providers [12][13][14][15][16][17][18][19]. Interventions to promote equity are often aimed at improving health care access and care for individuals and studied within the context of specific health issues such as diabetes [20], stroke [21], cancer screening [22], or organ transplant [23]. However, our research on health and health care inequities with Indigenous and non-Indigenous people pointed to the importance of intervention at the level of health care organizations [24][25][26][27].…”

EQUIP Emergency: Can interventions to reduce racism, discrimination and stigma in EDs improve outcomes?

“…Efforts to promote equity have been made at the national and international policy levels, and at the level of educating care providers (12)(13)(14)(15)(16)(17)(18)(19). Interventions to promote equity are often aimed at improving health care access and care for individuals and studied within the context of speci c health issues such as diabetes (20), stroke (21), cancer screening (22), or organ transplant (23). However, our research on health and health care inequities with Indigenous and non-Indigenous people pointed to the importance of intervention at the level of health care organizations (24)(25)(26)(27).…”