Racial Disparities in Access to Renal Transplantation — Clinically Appropriate or Due to Underuse or Overuse?
Arnold M. Epstein, M.D., John Z. Ayanian, M.D., M.P.P., Joseph H. Keogh, M.D., J.D., Susan J. Noonan, M.D., M.P.H., Nancy Armistead, M.P.A., Paul D. Cleary, Ph.D., Joel S. Weissman, Ph.D., Jo Ann David-Kasdan, R.N., M.S., Diane Carlson, Jerry Fuller, M.S.W., Douglas Marsh, and Rena M. Conti
Background Despite abundant evidence of racial disparities inthe use of surgical procedures, it is uncertain whether thesedisparities reflect racial differences in clinical appropriatenessor overuse or underuse of care.
Methods We performed a literature review and used an expertpanel to develop criteria for determining the appropriatenessof renal transplantation for patients with end-stage renal disease.Using data from five states and the District of Columbia onpatients who had started to undergo dialysis in 1996 or 1997,we selected a random sample of 1518 patients (age range, 18to 54 years), stratified according to race and sex. We classifiedthe appropriateness of patients as candidates for transplantationand analyzed data on rates of referral to a transplantationcenter for evaluation, placement on a waiting list, and receiptof a transplant according to race.
Results Black patients were less likely than white patientsto be rated as appropriate candidates for transplantation accordingto appropriateness criteria based on expert opinion (71 blacks[9.0 percent] vs. 152 whites [20.9 percent]) and were more likelyto have had incomplete evaluations (368 [46.5 percent] vs. 282[38.8 percent], P<0.001 for the overall chi-square). Amongpatients considered to be appropriate candidates for transplantation,blacks were less likely than whites to be referred for evaluation,according to the chart review (90.1 percent vs. 98.0 percent,P=0.008), to be placed on a waiting list (71.0 percent vs. 86.7percent, P=0.007), or to undergo transplantation (16.9 percentvs. 52.0 percent, P<0.001). Among patients classified asinappropriate candidates, whites were more likely than blacksto be referred for evaluation (57.8 percent vs. 38.4 percent),to be placed on a waiting list (30.9 percent vs. 17.4 percent),and to undergo transplantation (10.3 percent vs. 2.2 percent,P<0.001 for all three comparisons).
Conclusions Racial disparities in rates of renal transplantationstem from differences in clinical characteristics that affectappropriateness as well as from underuse of transplantationamong blacks and overuse among whites. Reducing racial disparitieswill require efforts to distinguish their specific causes andthe development of interventions tailored to address them.
Source Information
From the Department of Health Policy and Management, Harvard School of Public Health, Boston (A.M.E., R.M.C.); the Division of General Medicine, Section on Health Services and Policy Research, Brigham and Women's Hospital and Harvard Medical School, Boston (A.M.E., J.Z.A.); the Department of Health Care Policy, Harvard Medical School, Boston (A.M.E., J.Z.A., P.D.C., J.S.W.); CliGnosis, Boston (J.H.K., S.J.N., J.A.D.-K.); the Mid-Atlantic Renal Coalition, Midlothian, Va. (N.A.); the Institute for Health Policy, Massachusetts General Hospital, Boston (J.S.W.); the Renal Network of the Upper Midwest, St. Paul, Minn. (D.C.); Network 8, Jackson, Miss. (J.F.); and the Southern California Renal Disease Council, Hollywood (D.M.).
Address reprint requests to Dr. Epstein at the Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave., Boston, MA 02115, or at aepstein{at}hsph.harvard.edu.
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