Racial Disparities and Poverty in Access to Kidney Transplantation Pubblico
Patzer, Rachel Elizabeth (2011)
Abstract
ABSTRACT
Racial disparities in access to kidney transplantation are
evident among End Stage
Renal Disease (ESRD) patients, where black (vs. white) patients are
less likely to receive
a transplant. Socioeconomic status (SES) may play a role in both
the pediatric and adult
ESRD population. The purpose of this dissertation was to explore
the role of poverty and
race in access to kidney transplant among adult and pediatric ESRD
patients and to
evaluate the effectiveness of a patient education program at the
start of the renal
transplant evaluation process.
Data were abstracted from Emory Transplant Center (ETC) medical
records and
linked with data from a national ESRD surveillance system,
transplant registry, Census
(2000) and the American Community Survey (2005-2009). Multilevel
analytic
approaches were used to examine access to each transplant step by
race, testing for effect
modification between race and SES. To examine the effect of an
educational intervention
on evaluation completion, we calculated the time-period adjusted
probability of
evaluation completion by intervention group and examined the time
to evaluation
completion using Cox Proportional Hazards models.
Racial differences in renal transplant access were evident among
pediatric and
adult ESRD patients. Among children, black patients were 21% less
likely to receive a
transplant compared to whites (HR=0.79; 95% CI: 0.71-0.89). Racial
disparities in access
to the deceased donor waiting list were modified by SES, where
minority pediatric
patients with no health insurance experienced significant racial
disparities, but no
disparities were observed among those with private coverage. Among
adults, racial
disparities were observed in several transplant steps, where black
patients were 59% less
likely to receive a transplant at any given time vs. whites
(HR=0.41; 95% CI: 0.29-0.58).
SES did not explain the racial disparities in either pediatric or
adult transplantation. The
implementation of a patient education program increased evaluation
completion by 38%
(RR=1.38; 95% CI: 1.12-1.71), and had a stronger effect among black
and poor patients.
Findings suggest that earlier access to care may mitigate some
racial disparities, but
much of the disparity remains unexplained. Further research is
needed to identify
modifiable barriers to improve equitable access to renal
transplantation.
Table of Contents
TABLE OF CONTENTS
Chapter 1: Introduction
1
Chapter 2: Background and Literature Review
6
Chapter 3: General Methodological Issues
32
Chapter 4: Dissertation Data Sources
42
Chapter 5: Does Socioeconomic Status Explain the Racial
Disparities in
47
Pediatric Access to Kidney Transplantation?
Chapter 6: Race and Access to Renal Transplantation in the
Southeastern
77
United States
Chapter 7: Race and Poverty in the Evaluation of a Patient
Education
107
Program for Patients Referred for Renal Transplant
Chapter 8: Conclusions and Future Directions
133
References
142
Appendices
161
About this Dissertation
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