TRANSPLANTS: Race, Gender and Income Affect Allocation
Minorities, the poor and women are less likely to receive organ transplants compared to white, rich men, according to a new report in the Journal of the American Medical Association. Drs. Caleb Alexander and Ashwini Sehgal studied 7,125 kidney patients between 1993 and 1996 in Indiana, Kentucky and Ohio and found that African Americans are 32% less likely than whites to become definitely interested in transplants, 44% less likely to complete the tests necessary for the transplant and 50% less likely to get on an organ transplant waiting list and receive a new kidney (Srikameswaran, Pittsburgh Post-Gazette, 10/7). Women lagged behind men by 20% in the last three steps, and the poor were nearly 33% less likely than the rich to be designated as a candidate, express "definite interest" and undergo the pre-transplant workup. The Columbus Dispatch reports that while previous studies had highlighted how racial, gender and socio-economic factors impact the distribution of organs, the new JAMA article is the first to show differences in the pre-transplant process, indicating that many candidates never even reach the donor lists. Sehgal was "surprised by the results." He said, "In the past, everyone thought that the waiting list was the only important step in the process." The authors also found that the third step -- "pre-transplant evaluation" -- was a hurdle that barred many candidates, with only one-third of potential donors completing it (Somerson, 10/7).
Consumer advocacy group Public Citizen, calling the study "proof that the U.S. health care system discriminates," called for an expansion of a program that provides "case managers to help blacks, women and poor people navigate the medical system" (Tanner, AP/Philadelphia Inquirer, 10/7). Dr. Peter Lurie of Public Citizen's Health Research Group said, "These shameful biases in American Medicine must be eliminated. ... [M]ore attention will have to be paid to remedying the causes of the unjustifiable discrimination so clearly demonstrated at each and every step of the transplant process" (Public Citizen release, 10/6). The authors of the study state that they were not able to "determine why specific steps serve as barriers among blacks, women, and the poor," but cited as possible factors "lack of knowledge about transplantation and concerns about surgery, adverse effects of medication and health care costs." They concluded that a standardized national database of kidney patients is clearly needed, as there are "[c]urrently different coding systems ... among the 18 regional renal failure networks, and ... no national repository." Furthermore, they said "transplant and dialysis providers need to ensure that transplant candidates are identified equitably and then assisted through the transplantation process as expeditiously as possible" (Alexander/Sehgal, JAMA, 10/7 issue). Click here to see the study abstract.
A separate JAMA study reports that "[m]ost U.S transplant centers meet or exceed their expected survival rates," USA Today reports. The major threat to patients comes in the first year after undergoing a transplant, after which survival rates substantially increase, according to researchers from the United Network for Organ Sharing. Overall, survival rates have increased over the past ten years, assisted by new anti-rejection drugs, despite an older population of transplant patients (Rubin, 10/7). The researchers found that "98% of organs and 96% of recipients survived at least one year after transplantation," and "[l]ong-term survival for all organs exceeded 91%" (Pittsburgh Post-Gazette, 10/7). Additional factors boosting survival rates include improved "surgical techniques, better patient selection and the ability to treat certain kinds of infections," according to Dr. Doug Hanto (Hopkins, Cincinnati Enquirer, 10/7). Click here to see the study abstract.
The JAMA articles were interpreted by several doctors in the context of the recent controversy over pending changes in how organs are distributed nationwide. Changes urged by the federal government would shift the geographic-based distribution of organs to a system that would give preference to the sickest candidates nationwide. Dr. Sehgal said that because many blacks, women and poor people never reach the organ transplant list, the new UNOS distribution plan will fail to address the inequities in the current system (AP/Philadelphia Inquirer, 10/7). Dr. John Fung of the Starzl Transplantation Institute in Pittsburgh cited the increased transplant success rates in support of the new allocation rules. He said that a new nationalized organ distribution is "justified" because the JAMA study showed that the few transplant centers with substandard success rates were in small, local centers (Pittsburgh Post-Gazette, 10/7).
Simple Approaches Won't Work
A JAMA editorial by Dr. Edgar Milford of the New England Organ Bank contends that the two studies shed light on the "[f]our daunting problems confronting the solid organ transplant community: maximizing availability of transplants for patients, improving graft and patient survival rates, establishing an acceptable system for organ allocation, and making organ transplantation as cost-effective as possible." Milford cites problems with several different allocation models. While he says it is "possible to create a set of rules for cadaver solid organ transplantation that maximizes the number of additional years of patient life systemwide or that maximizes the number of years of transplant function," Milford says "[s]uch a purely utilitarian system of allocation would, no doubt, be unacceptable to many citizens because it would surely bias against transplantation of members of minority groups and older candidates." A "first- come, first-served" approach also may not be wise because it would "needlessly allocate particular available organs to individuals who are less likely to benefit from them than others on the current waiting list." He also says a "sickest patient first" approach "might be unwise if the long-term outcome of those patients is not as good as outcomes of patients who received their transplant earlier." Milford goes on to tout an approach taken by the New England Organ Bank and the Northeast Organ Procurement Organization. This approach, he notes, "takes into account patient urgency, waiting time, geographic relation of donor to recipient center, histocompatibility match, and candidate sensitization." He contends that this approach "has resulted in more equitable allocation to blacks and Hispanic persons while ensuring a reasonable amount of local access to kidneys" (10/7 issue). Click here to obtain the UNOS report on transplant success rates.