Kidney Transplantation and the Intensity of Poverty in the Contiguous United Sta

[Clark]

http://www.ncbi.nlm.nih.gov/pubmed/24809750

Kidney Transplantation and the Intensity of Poverty in the Contiguous United States.
Mohan S1, Mutell R, Patzer RE, Holt J, Cohen D, McClellan W.
Transplantation. 2014 May 7. [Epub ahead of print]

Abstract
BACKGROUND:
Geographic variation in kidney transplantation rates in the United States has been described previously but remains unexplained by age, race, sex, or socioeconomic status differences. Geographic variations in the concentration of poverty appear to impact end-stage renal disease care and potentially access to transplantation.
METHODS:
We studied the impact of how spatial topography of poverty across geographical regions in the contiguous United States is associated with kidney transplantation in the 48 contiguous U.S. states.
RESULTS:
We found considerable geographic variation in transplantation rates across the country that persisted across quartiles of county-level median household income and percentage minority population. Higher transplant rates were seen with increasing median household income and decreasing minority populations but were not influenced by education level. Transplantation rates in counties with poverty rates above the national average had low transplant rates, but these rates were influenced by the poverty level in the surrounding counties. Similarly, wealthy counties had higher transplant rates but were lowered in counties of relative wealth that were surrounded by less wealthy counties.
CONCLUSIONS:
Our results underline the geographical heterogeneity of kidney transplantation in the United States and identify regions of the country most likely to benefit from interventions that may reduce disparities in transplantation.
PMID: 24809750 [PubMed - as supplied by publisher]

[Clark]

http://www.ncbi.nlm.nih.gov/pubmed/24891223

Kidney Transplant Access in the Southeast: View From the Bottom.
Patzer RE1, Pastan SO.
Am J Transplant. 2014 May 29. doi: 10.1111/ajt.12748. [Epub ahead of print]

Abstract
The Southeastern region of the United States has the highest burden of end-stage renal disease (ESRD) but the lowest rates of kidney transplantation in the nation. There are many patient-, dialysis facility-, ESRD Network- and health system-level barriers that contribute to this regional disparity. Compared to the rest of the nation, the Southeast has a larger population of African-Americans and higher poverty, as well as more prevalent ESRD risk factors including hypertension, obesity and diabetes. Dialysis facilities-where ESRD patients receive the majority of their healthcare-play an important role in transplant access. Identifying characteristics of individual dialysis units with low rates of kidney transplantation, such as understaffing or for-profit status, can help identify targets for quality improvement initiatives. Geographic differences across the country can identify opportunities to increase funding for healthcare resources in proportion to patient and disease burden. Focusing interventions among dialysis facilities with the lowest transplant rates within the Southeast, such as provider and patient education, has the potential to increase referrals for kidney transplantation, leading to higher rates of kidney transplants in this region. Referral for transplantation should be measured on a national level to monitor disparities in early access to transplantation. Transplant centers have an obligation to assist underserved populations in ensuring equity in access to services. Policies that improve access to care for patients, such as the Affordable Care Act and Medicaid expansion, are particularly important for Southern states and may alleviate geographic disparities.

[Clark]

http://www.ncbi.nlm.nih.gov/pubmed/24891272

Dialysis Facility and Network Factors Associated With Low Kidney Transplantation Rates Among United States Dialysis Facilities.
Patzer RE1, Plantinga L, Krisher J, Pastan SO.
Am J Transplant. 2014 May 29. doi: 10.1111/ajt.12749. [Epub ahead of print]

Abstract
Variability in transplant rates between different dialysis units has been noted, yet little is known about facility-level factors associated with low standardized transplant ratios (STRs) across the United States End-stage Renal Disease (ESRD) Network regions. We analyzed Centers for Medicare & Medicaid Services Dialysis Facility Report data from 2007 to 2010 to examine facility-level factors associated with low STRs using multivariable mixed models. Among 4098 dialysis facilities treating 305 698 patients, there was wide variability in facility-level STRs across the 18 ESRD Networks. Four-year average STRs ranged from 0.69 (95% confidence interval [CI]: 0.64-0.73) in Network 6 (Southeastern Kidney Council) to 1.61 (95% CI: 1.47-1.76) in Network 1 (New England). Factors significantly associated with a lower STR (p < 0.0001) included for-profit status, facilities with higher percentage black patients, patients with no health insurance and patients with diabetes. A greater number of facility staff, more transplant centers per 10 000 ESRD patients and a higher percentage of patients who were employed or utilized peritoneal dialysis were associated with higher STRs. The lowest performing dialysis facilities were in the Southeastern United States. Understanding the modifiable facility-level factors associated with low transplant rates may inform interventions to improve access to transplantation.