Drs. Patzer and Pastan Examine Considerable Geographic Disparities in Access to Kidney Transplantation in the US

June 2014

Two papers by Emory transplant and epidemiology investigator Dr. Rachel Patzer and Emory nephrologist Dr. Stephen Pastan, also medical director of the kidney transplant program of the Emory Transplant Center, consider the substantial geographic variation in access to kidney transplantation among the more than 4000 US dialysis facilities that treat patients with kidney failure, particularly the disproportionate lack of access in the Southeast. The papers—e-published May 29 before print in the American Journal of Transplantation—describe factors that appear to explain these differences while also underscoring the need for political, financial, and health systems changes to reduce transplant inequities across the country.

In "Dialysis Facility and Network Factors Associated With Low Kidney Transplantation Rates Among United States Dialysis Facilities," the researchers reported that dialysis facilities in the Southeastern region of Georgia, North Carolina, and South Carolina had the lowest kidney transplant rates in the nation, and within these three states, Georgia had the lowest. The highest performing dialysis facilities were in the Northeast.

"The disparities that we have reported in access to kidney transplantation within dialysis facilities in the Southeastern US are linked to the higher concentration of poverty in this area of the country compared to other regions," said Dr. Patzer.  

The researchers noticed wide variability in transplant rates between different dialysis facilities, and then assessed what dialysis facility factors might play a role. The team looked for characteristics of dialysis facilities that were linked with delayed transplant access so they could begin distinguishing the modifiable facility-level factors associated with low transplant rates that may inform interventions to improve access to transplantation. When they analyzed Centers for Medicare and Medicaid Services Dialysis Facility Report data from 2007 to 2010, they found that dialysis facilities with a higher proportion of African American patients, uninsured patients, and patients with diabetes had lower rates of kidney transplantation. In addition, facilities owned by for-profit companies and facilities with fewer staff tended to have lower rates. Facilities located in a region with more transplant centers per 10,000 kidney failure patients and that had a higher percentage of patients who were employed tended to have higher rates of transplantation.

"Identifying the characteristics of dialysis facilities that are associated with poor access to kidney transplantation helps us to target interventions," Dr. Patzer said.

In their viewpoint article "Kidney Transplant Access in the Southeast: View From the Bottom," Dr. Patzer and Dr. Pastan focus on the conditions in the Southeast that have contributed to the region having the highest levels of kidney disease but the lowest rates of kidney transplantation in the nation, and propose several strategies for overcoming this imbalance and striving for geographic equity in healthcare access and outcomes. Factors shaping the disparity include the region having a larger population of African-Americans—the authors assert that "minority race/ethnicity is associated with poor health outcomes in the United States"—and higher poverty than the rest of the nation, as well as more prevalent risk factors for kidney disease, including hypertension, obesity, and diabetes. Considering the essential role dialysis facilities play in transplant access, the authors posit that identifying characteristics of individual dialysis units with low rates of kidney transplantation, such as understaffing or for-profit status, can help identify targets for internal quality improvement initiatives. They also suggest that coordinated policy changes by organizations such as transplant centers could increase staffing, standardize patient education, and expand Medicaid eligibility.

"We think these results are important because identifying the regions of the country with the greatest disparity in access to kidney transplantation could help policy makers to direct funding to support solutions to address these disparities, as well as help researchers to develop and test interventions to reduce these disparities," said Dr. Patzer.

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