Unexpected Race and Ethnicity Differences in the US National Veterans Affairs Kidney Transplant Program

Myaskovsky, Larissa; Kendall, Kay; Li, Xingyuan; Chang, Chung Chou H.; Pleis, John R.; Croswell, Emilee; Ford, C. Graham; Switzer, Galen E.; Langone, Anthony; Mittalhenkle, Anuja; Saha, Somnath; Thomas, Christie P.; Flohr, Jareen Adams; Mohan, Ramkumar; Dew, Mary Amanda

doi:10.1097/tp.0000000000002905

Cited by 11 publications

(8 citation statements)

References 81 publications

(160 reference statements)

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“…73 of our candidates and is on the upper end of the spectrum compared to prior reports of PTSD in VA populations 18,67,68 and is higher than the 4% rate of PTSD among post-kidney transplant Veterans reported by Evans. 19 Thirty-one percent of our candidates overall and about 26% of the listed patients were diagnosed with depression which is close to previously reported ranges for prevalent depression among dialysis (39%), 2 waitlisted (33-52%), 5,6 and post-kidney transplant (2.8-31%) 5-10 patients. However, the rates of depression and anxiety (16%) in our cohort are higher than the moderate depression (2.8%) and anxiety (1.5%) assessed using the Brief Symptom Inventory (BSI) by…”

Section: Discussionsupporting

confidence: 86%

“…Freeman and Myaskovsky in contemporaneous VA kidney transplant candidates. 5,50 The rates reported by Freeman and Myaskovsky are also low compared with the 25% estimated rate of depression in the general VA population and seem low considering that almost 18% of our patients were taking an antidepressant. Questionnaires are known to estimate higher depression rates, 69 thus the low rates obtained via the BSI are surprising, but could perhaps be partially explained by undercounting patients receiving effective treatment.…”

Section: Discussionmentioning

confidence: 55%

“…Mental health and psychosocial issues are common among renal failure and kidney transplant candidates and are associated with short and long-term outcomes. [1][2][3][4][5][6][7][8][9][10][11][12][13][14] Therefore, these issues are considered in the transplant evaluation process. 15,16 While pretransplant mental health evaluation methods are variable across the United States, 13,14,17 to accommodate the high rate of mental health issues among Veterans, [18][19][20] the VA kidney transplant evaluation process was developed to include both a social work and psychological evaluation for each candidate prior to an onsite evaluation.…”

Section: Introductionmentioning

confidence: 99%

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Psychosocial characteristics of patients evaluated for kidney transplant and associations with functional and frailty metrics at a veterans affairs hospital

Manay

Eyck

Siniff

et al. 2021

Clinical Transplantation

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Background:The effect of psychosocial problems on listing outcomes and potential interactions with functional metrics is not well-characterized among Veteran transplant candidates. Methods:The results from psychosocial evaluations, frailty metrics, and biochemical markers were collected on 375 consecutive Veteran kidney transplant candidates. Psychosocial diagnoses were compared between patients listed or denied for transplant.Functional abilities were compared among patients with or without psychosocial diagnoses and then evaluated based on reason for denial.Results: Eighty-four percent of patients had a psychosocial diagnosis. Common issues included substance or alcohol abuse (62%), psychiatric diagnoses (50%), and poor adherence (25%). Patients with psychiatric diagnoses, cognitive impairments, and poor adherence were more likely to be denied for transplant (P < .05). Patients with depression, PTSD, and anxiety did not have worse functional ability, but experienced more exhaustion than patients without these problems. Patients denied for medical but not purely psychosocial reasons had worse troponin and functional metrics compared with listed patients. Conclusion:Over 80% of patients with a psychosocial diagnosis were listed; however, poor adherence was a particularly important reason for denial for purely psychosocial reasons. Patients with psychosocial diagnoses generally were not more functionally limited than their counterparts without psychosocial diagnoses or those listed for transplant.

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Section: Discussionsupporting

confidence: 86%

Section: Discussionmentioning

confidence: 55%

Section: Introductionmentioning

confidence: 99%

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Psychosocial characteristics of patients evaluated for kidney transplant and associations with functional and frailty metrics at a veterans affairs hospital

Manay

Eyck

Siniff

et al. 2021

Clinical Transplantation

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“…Both race and gender have been independently associated with decreased likelihood of completing the evaluation process, with significant interaction between race and income as well as gender and income [ 49 , 50 ]. Black patients were found to be 25% less likely (95% CI 0.60–0.96) to be waitlisted than White patients even after adjusting for medical factors and other social determinants of health.…”

Section: Resultsmentioning

confidence: 99%

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

Park

Jones

Kaplan

et al. 2022

Int J Equity Health

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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.

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“…Our study may help explain why income was not associated with likelihood of listing in VA settings (18). The VA, by offering medical care with financial support in the form of medical tests, travel, and lodging during evaluation, may be mitigating differences in SES (18), and thereby reducing racial disparities in kidney transplantation (31). Candidates with greater comorbidity, who are often of low SES, may require extensive evaluation.…”

Section: Discussionmentioning

confidence: 80%

Association of Socioeconomic Status and Comorbidities with Racial Disparities during Kidney Transplant Evaluation

Murphy

Jackson

Purnell

et al. 2020

CJASN

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Background and objectivesBlack patients referred for kidney transplantation have surpassed many obstacles but likely face continued racial disparities before transplant. The mechanisms that underlie these disparities are unclear. We determined the contributions of socioeconomic status (SES) and comorbidities as mediators to disparities in listing and transplant.Design, setting, participants, & measurementsWe studied a cohort (n=1452 black; n=1561 white) of patients with kidney failure who were referred for and started the transplant process (2009–2018). We estimated the direct and indirect effects of SES (self-reported income, education, and employment) and medical comorbidities (self-reported and chart-abstracted) as mediators of racial disparities in listing using Cox proportional hazards analysis with inverse odds ratio weighting. Among the 983 black and 1085 white candidates actively listed, we estimated the direct and indirect effects of SES and comorbidities as mediators of racial disparities on receipt of transplant using Poisson regression with inverse odds ratio weighting.ResultsWithin the first year, 876 (60%) black and 1028 (66%) white patients were waitlisted. The relative risk of listing for black compared with white patients was 0.76 (95% confidence interval [95% CI], 0.69 to 0.83); after adjustment for SES and comorbidity, the relative risk was 0.90 (95% CI, 0.83 to 0.97). The proportion of the racial disparity in listing was explained by SES by 36% (95% CI, 26% to 57%), comorbidity by 44% (95% CI, 35% to 61%), and SES with comorbidity by 58% (95% CI, 44% to 85%). There were 409 (42%) black and 496 (45%) white listed candidates transplanted, with a median duration of follow-up of 3.9 (interquartile range, 1.2–7.1) and 2.8 (interquartile range, 0.8–6.3) years, respectively. The incidence rate ratio for black versus white candidates was 0.87 (95% CI, 0.79 to 0.96); SES and comorbidity did not explain the racial disparity.ConclusionsSES and comorbidity partially mediated racial disparities in listing but not for transplant.

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Unexpected Race and Ethnicity Differences in the US National Veterans Affairs Kidney Transplant Program

Cited by 11 publications

References 81 publications

Psychosocial characteristics of patients evaluated for kidney transplant and associations with functional and frailty metrics at a veterans affairs hospital

Psychosocial characteristics of patients evaluated for kidney transplant and associations with functional and frailty metrics at a veterans affairs hospital

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

Association of Socioeconomic Status and Comorbidities with Racial Disparities during Kidney Transplant Evaluation

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