Comparable Barriers to Access to Kidney Transplantation Across National Lines

Factors associated with patients' progression toward receiving a kidney transplant have been investigated in numerous studies over the past decades. Findings from these studies indicate that both patient- and provider-level factors have a significant association with patients' timing and likelihood to be placed on the kidney transplant waiting list and ultimately to receive a transplant. The current study by Dudley et al. (1) investigates factors associated with dialysis patients' propensity to be wait listed in the United Kingdom. This is an important study as it investigates potential access barriers to kidney transplantation in a novel population, in a country with distinct healthcare structure. This study uses a unique combination of patient and provider factors to assess their independent association with dialysis patients' likelihood to be listed for transplantation. As timely access to transplantation has been demonstrated to improve survival before and after the transplant procedure, efforts to characterize patients that are less likely to receive equitable care are critical (2, 3). The primary findings of the study suggest that advanced age, certain primary diagnoses, no prior history of transplantation, white ethnicity, and increased social deprivation are significant patient-level factors associated with a reduced probability of being listed for transplantation. Furthermore, larger renal units, centers with smaller living donor programs and centers with different listing practices for living donor recipients were significant center-level factors associated with reduced probability of listing. Cumulatively, these findings support most prior research findings in a unique environment and suggest that attention to particular facility-level characteristics is also important to consider with dialysis patients' access to care. Numerous patient characteristics are associated with the likelihood of progression toward acquiring a kidney transplant. Among previously documented factors are history of diabetes and other comorbidities, patient age, gender, race/ethnicity, income, educational attainment, and prior transplantation. Along with confirming several of these factors in a novel population, this study suggests that these are not necessarily attributable to the healthcare structure in other countries such as the United States where healthcare comparably may be considered more fragmented. One factor which has been explicitly attributed to delayed placement on waiting lists and is suggested by these data is patients' social class. This association may be reflective of educational attainment, social networks, health literacy, or logistical impediments among other factors. This study confirms that this association is prevalent in a nation with a more socialized form of healthcare, which intuitively could be thought to diminish disparities in care. In contrast to studies describing the United States population, white race ethnicity was associated with a lower propensity to be listed. As race/ethnicity definitions may represent different heritage in different countries, these results are interesting and suggestive that minority race per se may not be the driving factor in differential propensity toward access to care. One factor that has been demonstrated to attenuate the association between African American race and reduced likelihood to be placed on waiting lists in the United States is individual patient preferences. Therefore, we cannot rule out the possibility that at least a portion of these findings illustrates patient decisions along with other health conditions not codified in this study rather than systematic deficiencies alone. This is critical to understand prospectively and is what distinguishes what many would consider healthcare disparities as opposed to differences in access to care. The significance of the difference between race/ethnic groups were eliminated with the inclusion of comorbidity data available in only a subset of patients, but even equivalent likelihood of listings between race/ethnic groups is interesting and further evaluation of differences between this population and other countries is worthy of follow-up study. A novel contribution of this study is to jointly examine the association of patient- and center-level factors with outcomes in the primary analysis. In fact, center-level factors had a substantial association with patients' likelihood to be wait-listed in this study. The concept that particular providers of care may influence patient outcomes has also been documented in other studies for these populations (4, 5). Although it is important to exercise caution with the interpretation of these findings (as there are still many factors not considered in this model that may ultimately influence patients' viability as candidates) there is also little doubt that variability exists in the protocols that dialysis centers use for listing patients. In particular, identifying specific protocols that dialysis centers can use to facilitate rapid listing may be an important follow-up study. As suggested by this study, there may be center practices that can be identified and potentially broadly incorporated to facilitate rapid listing equitably to dialysis patients. Furthermore, it should not be ignored that there may be an interaction of patient characteristics and provider-level factors that was not elucidated in this study. That is, it is certainly conceivable that the same patients that have improved access to the waiting list are located or seek out providers that use protocols or have resources that optimize their care. Understanding these relationships may not only elucidate provider factors that can improve patients' access to care but potentially reduce disparities among certain portions of the population. Evaluation and identification of patterns of differences (or disparities) in access to care are clearly important topics for research. In the United States, perhaps one-third of the end-stage renal disease population that has a relatively long life expectancy and presumably may be viable for transplantation are not listed within 1 year of end-stage renal disease onset (6). Importantly, we should not be resigned to simply acknowledge these phenomena. Despite the fact that these associations have been examined for more than a decade, there is little evidence to suggest that patterns have changed on a broad level. This article suggests that perhaps there has been a minor shift in patient listings following dissemination of these data, but most likely substantive changes in disparities in care will only be accompanied by interventional programmatic efforts and widespread support. Further identification of the most effective interventions to ameliorate differences in access to care and elevated prioritization of these issues are vital in the years to come.