The Influence of Socioeconomic Status and Minority Race on Referral for Kidney Transplantation in Georgia Open Access

Parulekar, Shruti (2016)

Permanent URL: https://etd.library.emory.edu/concern/etds/pk02cb21v?locale=en
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Abstract

Introduction

Racial and socioeconomic disparities in access to kidney transplantation have been previously documented, however, a prior study in Georgia found that African Americans were more likely to be referred for transplantation and yet less likely to be waitlisted. Little is known about whether racial disparities in transplant referral vary across levels of socioeconomic status (SES) of a patient and the neighborhood in which they reside.

Methods:

Patient referral data from January 2005 to September 2011 was obtained from the Reducing Disparities in Access to Kidney Transplantation (RaDIANT) Community Study and linked to the US Renal Data System (USRDS) and US Census Data. Race was defined as African American, white Hispanic, white non-Hispanic and other. Individual level SES was defined using insurance status and pre-ESRD nephrology care; neighborhood level SES was defined using neighborhood poverty levels and percentage of high school graduates. The outcome was referral for transplant evaluation. Multivariable Cox models adjusted for demographics and dialysis facility characteristics were used to examine whether racial disparities in access to referral for transplantation varied across SES measures.

Results:

Overall, 5362 (35.9%) patients were referred for kidney transplantation after starting dialysis. The median time from dialysis start to referral was 624 days (IQR: 182 - 1417). No statistically significant interaction was seen between race and SES. Among patients with no insurance, African Americans were three times more likely to be referred for transplant one year after starting dialysis compared to whites (HR= 3.32 , 95% CI: 1.31 - 8.40)). Among patients referred for transplant within one year after starting dialysis, African Americans living in neighborhoods 15-30% below the poverty level were 61% more likely to be referred for transplant compared to whites (HR= 1.61, 95% CI: (1.11 - 1.23)). Among those living in neighborhoods with less than 80% high graduates, African Americans were 94% more likely to be referred for transplant within one of starting dialysis compared to whites (HR= 1.94, 95% CI: (1.02 - 3.68 )).

Conclusion:

These results suggest that racial disparities in access to kidney transplantation vary by a patient's SES.

Table of Contents

Chapter I: Background .................................................................................. 1

Prevalence and Burden of End Stage Renal Disease................................................ 1

Treatment for End Stage Renal Disease ............................................................... 2

Disparities in Renal Transplant............................................................................ 3

Geographic Disparities in Access to Kidney Transplantation ...................................... 4

RaDIANT Community Study................................................................................ 5

Process of Transplant and Referral to Transplant................................................... 6

Factors associated with kidney transplant............................................................ 8

Importance of Socioeconomic Status in Access to Transplant Referral........................9

Indicators used for measuring socioeconomic status.............................................. 10

Chapter II: Manuscript ................................................................................. 13

Introduction ................................................................................................. 14

Methods ...................................................................................................... 17

Data Sources................................................................................................ 17

Study Population .......................................................................................... 17

Study Variables ............................................................................................ 18

Data Analysis ............................................................................................... 19

Results ........................................................................................................ 20

Characteristics of Patients referred for transplantation.......................................... 20

Association between Patient Characteristics and Referral for Transplantation............. 21

Influence of interaction between race and SES on the Referral for Transplantation...... 22

Discussion .................................................................................................... 23

Study Limitations ........................................................................................... 26

Conclusions .................................................................................................. 27

References ................................................................................................... 28

Tables ......................................................................................................... 37

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