Racial Differences in Patient Perceived Barriers to Starting the Pre-Kidney Transplant Evaluation Pubblico
Hamoda, Reem (Spring 2018)
Abstract
Objective: Racial disparities in access to kidney transplantation, the preferred treatment option for end stage renal disease (ESRD), persist along multiple steps of the transplant process. However, it is unclear what patient-level barriers perpetuate disparities in starting the pre-kidney transplant evaluation. We aimed to evaluate racial differences (black versus white, non-Hispanic) in patient-perceived barriers to starting the evaluation at a transplant center. Methods: In a telephone survey to 528 ESRD patients referred for kidney transplantation in 2016 to one of three Georgia transplant centers, we administered a 17-item Barriers to Transplantation scale assessing patient-perceived barriers to evaluation start. Agreement to each item was rated on a 5-point Likert scale. Using exploratory factor analyses, we derived three subscales representing financial, logistical, or belief-based barriers to transplantation. Multivariable logistic regression was used to evaluate associations between overall scale and subscales and evaluation start, adjusting for patient characteristics and assessing effect modification by race. Effect decomposition methods were used to evaluate the role of each barrier type in the association between race and evaluation start. Results: After applying relevant exclusion criteria, our study population consisted of 416 patients, 50% of whom did not start the evaluation. Compared to whites, blacks (n=209) were younger (mean: 54 ± 12 years), more likely to have public insurance (27%) (p<0.01), and less likely to complete high school (34%) (p<0.01). Blacks were 29% less likely to start the evaluation compared to whites (OR for not starting evaluation: 1.71, 95% CI: 1.09, 2.70). Significant barriers experienced among blacks included concerns about transplant wait time, finding a living donor, affording transplantation, and finding transportation. In adjusted analyses, increases in the Barriers to Transplantation (OR: 1.71, 95% CI: 1.09, 2.68) and Logistical Concerns scales (OR: 1.76, 95% CI: 1.25, 2.47) were significantly associated with not starting the evaluation. Associations between each scale and evaluation start did not significantly differ by race; however, logistical concerns explained 21.1% of racial differences in evaluation start. Conclusion: Black (versus white) patients disproportionately experience barriers to starting the evaluation. Development of interventions targeting barriers to evaluation start may be needed to reduce racial disparities in kidney transplantation.
Table of Contents
Chapter 1: Background ..........................................................................1
Chronic kidney disease (CKD) .................................................................1
End stage renal disease (ESRD) ..............................................................3
Treatment options for ESRD ...................................................................7
Access to kidney transplantation ...........................................................10
Summary ...........................................................................................12
Chapter 2: Manuscript .........................................................................13
Abstract ............................................................................................13 I
ntroduction .......................................................................................14
Methods ............................................................................................15
Objective ...........................................................................................15
Survey development ............................................................................16
Subscale development ..........................................................................16
Study population ..................................................................................17
Data collection and quality control assessment .........................................18
Outcomes of interest .............................................................................19
Exposure of interest and additional measures ...........................................19
Data analysis .......................................................................................20
Results ................................................................................................21
Study population ...................................................................................21
Descriptive analyses ..............................................................................22
Congruent validity of Barriers to Transplantation subscales .........................23
Associations between scales and evaluation start........................................23
The role of Barriers to Transplantation in racial differences in evaluation start... 24
Discussion .............................................................................................25
Chapter 3: Public Health Implications ........................................................33
References .............................................................................................37
Tables ......…….........................................................................................46
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