Stark Racial Disparities in Kidney Disease Treatment
Reducing negative perceptions of health care may reduce disparities.
Posted Mar 16, 2015
By Larissa Myaskovsky
African-American, Hispanic, and Native American patients are twice as likely as whites to develop end-stage kidney disease, but only half as likely to complete transplant evaluation and receive a kidney transplant. Currently, more than 390,000 people are treated for end-stage kidney disease (ESKD) in the United States, and another 7.4 million people have chronic kidney disease, which typically advances to ESKD.
With the goal of helping to reduce disparities, I am leading a new research study under the auspices of the Center for Research on Healthcare at the University of Pittsburgh and funded by the National Institute of Diabetes, Digestive and Kidney Diseases. We will be testing the efficacy and cost effectiveness of a comprehensive, system-level fast-track kidney transplant evaluation for minorities. Eventually, we aim to reduce time-to-complete transplant evaluation and increase kidney transplantation.
The best treatment for end-stage kidney disease is a living-donor kidney transplant (LDKT). But the evaluation process for a kidney transplant is lengthy, time-consuming, and burdensome to the patient. Also, race disparities exist in rates of transplant evaluation completion, transplantation, and LDKT. My previous and ongoing research indicates that cultural factors (i.e., perceived discrimination in health care, religious objection to LDKT), transplant knowledge, and demographic characteristics (e.g., age, education, and income) independently and significantly predict the time needed to complete transplant evaluation.
In December 2012, the University of Pittsburgh’s transplant center implemented a one-day, streamlined evaluation process, dubbed Kidney Transplant Fast Track (KTFT), but it has not been evaluated for efficacy or cost effectiveness. This new study will determine the efficacy and cost-effectiveness of the fast-track program compared to a matched historical control group who participated in my previous work. An important aspect of this project, and what may be of particular interest to SPSSI members, is that we will determine whether engaging in this comprehensive, streamlined, and coordinated-care evaluation experience may reduce negative perceptions of the health care system (i.e., whether it may lower levels of medical mistrust, perceived discrimination, and perceived racism in health care).
At the same time, the team will conduct a randomized controlled trial with an educational component called the TALK intervention (Talking About Live Kidney Donation) to increase LDKT. For both components of the proposal, vulnerable populations (e.g., minorities, low-SES patients) will be targeted because they are most at risk for extended evaluation times and lower rates of LDKT. Participants will be randomly assigned to TALK versus no-TALK conditions and will undergo two interviews, at pretransplant work-up and at completion-of-transplant evaluation, in order to
(1) test whether KTFT and TALK will reduce transplant evaluation time and increase rates of transplant and LDKT in members of vulnerable groups;
(2) determine whether engaging in a streamlined and coordinated-care evaluation experience within the transplant center reduces negative perceptions of the health care system; and
(3) test the cost effectiveness of the KTFT with TALK relative to standard practices.
The results of this two-pronged approach will help pave the way for other transplant centers to implement a fast-track system at their sites, improve quality of care by transplanting a larger number of vulnerable patients, and may help address stark race/ethnic disparities in rates of LDKT. We hope to have preliminary, actionable results by January, 2017.
Larissa Myaskovsky is an Associate Professor of Medicine, Psychiatry, and Clinical and Translational Science at the University of Pittsburgh.