New System Reduces Kidney Transplant Disparities

Veronica Hackethal, MD

June 05, 2017

A new allocation system implemented by the United Network for Organ Sharing (UNOS) may decrease ethnic/racial disparities in kidney transplantation, according to a study published online today in Health Affairs.

In the first 22 months after implementation, transplantation rates rose for blacks and Hispanics and decreased for whites compared with the last 18 years under the old allocation system.

"The policy change appears to have at least temporarily eliminated racial and ethnic disparities in access to kidney transplantation for waitlisted black and Hispanic patients," first author, Taylor Melanson, a doctoral student in the Laney Graduate School at Emory University, Atlanta, Georgia, said in a press release.

"This is a very positive achievement, but continued efforts are needed to address the disparities that exist prior to waitlist, including the racial and ethnic differences in completing the medical evaluation process to be placed on the waitlist," Melanson added.

Because the demand for kidneys "far surpasses" the supply, Melanson continued, the increased rates of transplants for blacks and Hispanics will result in fewer transplants for whites unless the overall number of organs available increases. 

"Increasing kidney donations should be the next policy target to ensure both equitability and improved transplant access," Melanson stressed.

In 2014, almost 700,000 people in the United States had end-stage renal disease, at a cost of $32.8 billion for Medicare. The preferred treatment for end-stage renal disease is kidney transplantation, which can extend survival, improve quality of life, and decrease hospitalizations compared with dialysis.  Transplantation also costs about 30% less than staying on dialysis, according to background information in the article.

The new UNOS system was implemented in December 2014. Under both the old and new system, the primary factor for determining priority level for transplant is how long a patient has been on the waitlist. However, the new system uses either the date a patient was added to the waitlist or the date of the person's first dialysis, whichever is earliest. By contrast, the old system used only the date a patient was added to the waitlist. This change targets disparities because black and Hispanic patients often spend more time on dialysis before being waitlisted than do white patients.

To evaluate whether the new allocation system made a difference, Melanson and colleagues assessed records from 179,071 patients who were wait-listed between June 2013 and September 2016. They also evaluated dialysis time for 34,133 individuals who underwent kidney transplantations.

Because the new system is set up for organ transplants from deceased donors, the study did not include transplants from living donors. It focused on white, black, and Hispanic patients and excluded other racial/ethnic groups.

During the 18-month preimplementation period (June 2013 through November 2014), whites had higher monthly average transplantation rates (1.07%) compared with blacks (0.80%) or Hispanics (0.79%).

During the 22-month implementation period (December 2014 to September 2016), transplantation rates decreased significantly for whites (0.95%; P < .001), increased significantly for blacks (0.96%; P <.001), and increased significantly for Hispanics (0.91%; P <.01).   

Disparities in transplantation rates narrowed by 0.29 percentage point for blacks compared with whites and by 0.24 percentage point for Hispanics compared with whites. Whereas differences in monthly average transplantation rates were significant for whites compared with blacks and Hispanics before the implementation, these differences became nonsignificant after implementation.  

The authors also found that time on dialysis lengthened for all groups. This result is expected when patients who spend more time on dialysis receive higher priority, according to the authors.

However, if prioritizing such individuals drove disparity reductions, transplant rates may go back to previous levels over time, they add. Ongoing data already suggest that time on dialysis is trending downward among waitlisted individuals and that the system's effect on this factor may decrease as the most disadvantaged patients exit the list.

"It will be important to do additional follow-up and monitoring on the effects of the UNOS policy to fully understand the longer-term consequences and maintain and improve on the disparity reductions. If the disparity reduction is sustained, the kidney allocation system will serve as a valuable example of how health policy can be shaped to immediately reduce racial and ethnic disparities in our health care system." senior author, Rachel Patzer, MD, PhD, assistant professor in the Department of Surgery and Department of Medicine at the Emory University School of Medicine, said in a press release.

The authors note several limitations, including the possibility that full implementation of the system may take time. However, they would expect such an effect to underestimate the system's impact.

The study was supported by the National Institute on Minority Health and Health Disparities and in part by Health Resources and Services Administration. The authors have disclosed no relevant financial relationships.

Health Aff.  2017;36:1078-1085. Abstract

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