Rates of Solid-Organ Wait-listing, Transplantation, and Survival Among Residents of Rural and Urban Areas

Department of Surgery, Dartmouth Medical School, Lebanon, New Hampshire, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 01/2008; 299(2):202-7. DOI: 10.1001/jama.2007.50
Source: PubMed


Disparities in access to organ transplantation exist for racial minorities, women, and patients with lower socioeconomic status or inadequate insurance. Rural residents represent another group that may have impaired access to transplant services.
To assess the association of rural residence with waiting list registration for heart, liver, and kidney transplant and rates of transplantation among wait-listed candidates.
Five-year US cohort of 174,630 patients who were wait-listed and who underwent heart, liver, or kidney transplantation between 1999 and 2004.
Rates of new waiting list registrations and transplants per million population for residents of 3 residential classifications (rural/small town population, <10,000; micropolitan, 10,000-50,000; and metropolitan >50,000 or suburb of major city).
Compared with urban residents, waiting list registration rates for rural/small town residents were significantly lower for heart (covariate-adjusted rate ratio [RR] = 0.91; 95% confidence interval [CI], 0.86-0.96; P<.002), liver (RR = 0.86; 95% CI, 0.83-0.89; P<.001), and kidney transplants (RR = 0.92; 95% CI, 0.90-0.95; P<.001). Compared with residents in urban areas, rural/small town residents had lower relative transplant rates for heart (RR = 0.88; 95% CI, 0.81-0.94; P = .004), liver (RR = 0.80; 95% CI, 0.77-0.84; P<.001), and kidney transplantation (covariate-adjusted RR = 0.90; 95% CI, 0.88-0.93; P<.001). These disparities were consistent across national organ allocation regions. Significantly longer waiting times among rural patients wait-listed for heart transplantation were observed but not for liver and kidney transplantation. There were no significant differences in posttransplantation outcomes between groups.
Patients living in rural areas had a lower rate of wait-lisiting and transplant of solid organs, but did not experience significantly different outcomes following transplant. Differences in rates of wait-listing and transplant may be due to variations in the burden of disease between different patient groups or barriers to evaluation and waiting list entry for rural residents with organ failure.

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    • "Despite well-known advantages of renal transplant, there is a wide geographic variation in the rate of kidney transplant (8, 9). Patients living in rural regions are up to 15% less likely to be placed on the waiting list (10). The contribution of patient attitudes and perceptions to geographic disparities in transplant rates is not well defined. "
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    ABSTRACT: Chronic kidney disease (CKD) is a worldwide public health problem with increasing incidence and prevalence and associated expenses. To explore different perceptions of rural and urban patients with chronic kidney disease (CKD) about kidney transplant. We conducted four focus groups, each including 5 or 6 patients with stage 5 CKD or end stage renal disease living in a rural or urban area. Open-ended questions probed patient familiarity with kidney transplant, perceptions of benefits of kidney transplant, perceived barriers to kidney transplant, and views about living donation. All the sessions were recorded and professionally transcribed. Responses were pooled, de-identified, and analyzed using qualitative thematic content analysis. Urban patients were more likely to receive supplementary information and being strongly encouraged by their nephrologists to seek transplant. All participants acknowledged "independence" as the main advantage of transplantation. Increased freedom to travel and improved life expectancy were mentioned only among the urban groups. The main themes in all groups regarding perceived barriers to transplant were the tedious pre-transplant testing and workup expenses. Among rural groups, there was a perception that distance from transplant centers impedes transplant evaluation. Religious reasons favoring and opposing transplant were mentioned by participants in a rural group. Some members contended that since illness is God's will, we should not change it. Others in the same group argued that "God is not ready for us to give up". Praise and gratitude for the living donor were expressed in all groups, but concerns about donor's outcome were discussed only within the rural groups. In discussing preference about known or anonymous donors, members of an urban group mentioned favoring an anonymous donor, citing unease with a sense of life-long indebtedness. Observed differences in perceptions among rural and urban patients about aspects of transplant may contribute to geographic disparities in transplant. The findings could be helpful to guide future individualized, culturally sensitive educational interventions about transplant for patients with CKD.
    03/2014; 6(2):e15726. DOI:10.5812/numonthly.15726
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    • "This same study reported that disparities in race and ethnicity are largely explained by the aforementioned factors. Another study found significant differences in the waiting list registration rates, relative transplant rates, and waiting times for transplant patients who were living in rural versus urban locations (5). We sought to identify individual barriers to kidney transplantation not previously identified by surveying patients who were referred for kidney transplant evaluation, but who never followed up on the referral. "
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    ABSTRACT: End-stage renal disease affects many Americans; however, transplant is the best treatment option increasing life years and offering a higher quality of life than possible with dialysis. Ironically, many who are eligible for transplant do not follow through on the complex workup protocols required to be placed on the transplant waiting list. Here we surveyed vascular access clinic patients at an academic medical center referred for transplant, who did not follow up on the needed workup to be added to the national transplant waiting list. The most frequent responses of 83 patients for not pursuing transplantation were that the patients did not think they would pass the medical tests, they were scared of getting a transplant, and they could not afford the medicine or the transplantation. These impediments may result from unclear provider communication, misinformation received from peers or other sources, misperceptions related to transplant surgery, or limited health literacy/health decision-making capacity. Thus, patients with end-stage renal disease lost to follow-up after referral for kidney transplant faced both real and perceived barriers pursuing transplantation.
    Kidney International 07/2012; 82(9):1018-23. DOI:10.1038/ki.2012.255 · 8.56 Impact Factor
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    • "Disparities in healthcare and clinical outcomes have been documented, and it has been demonstrated that socially disadvantaged individuals may have inferior medical outcomes; in particular, African Americans [1, 2], women [3], and residents of rural as opposed to urban regions [4] are generally considered at risk of inferior outcome. However, defining an underprivileged population based on rigid criteria of skin color, gender, or geographic location may be prone to errors lacking specificity and sensitivity. "
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    ABSTRACT: Definitions of underprivileged status based on race, gender and geographic location are neither sensitive nor specific; instead we proposed and validated a composite index of social adaptability (SAI). Index of social adaptability was calculated based on employment, education, income, marital status, and substance abuse, each factor contributing from 0 to 3 points. Index of social adaptability was validated in NHANES-3 by association with all-cause and cause-specific mortality. Weighted analysis of 19,593 subjects demonstrated mean SAI of 8.29 (95% CI 8.17-8.40). Index of social adaptability was higher in Whites, followed by Mexican-Americans and then the African-American population (ANOVA, p < 0.001). The SAI was higher in subjects living in metropolitan compared to rural areas (T-test, p < 0.001), and was greater in men than in women (T-test, p < 0.001). In Cox models adjusted for age, comorbidity index, BMI, race, sex, geographic location, hemoglobin, serum creatinine, albumin, cholesterol, and glycated hemoglobin levels, SAI was inversely associated with mortality (HR 0.87 per point, 95% CI 0.84-0.90, p < 0.001). This association was confirmed in subgroups. We proposed and validated an indicator of social adaptability with a strong association with mortality, which can be used to identify underprivileged populations at risk of death.
    08/2011; 7(4):720-7. DOI:10.5114/aoms.2011.24145
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