Unemployment restricts access to kidney transplants, UNH research finds

August 20, 2013

DURHAM, N.H. - People in end-stage kidney failure in need of a kidney transplant are much less likely to be placed on a waiting list for a new kidney or to actually receive a new kidney once on the list if they are unemployed or work part time, according to new collaborative research from the University of New Hampshire.

"There is a strong negative association between a patient's unemployment and the likelihood of being placed on a waiting list for a kidney transplant, and once on the waiting list, the likelihood of receiving a transplant," says Robert Woodward, the Forrest D. McKerley Endowed Chair in Health Economics at the University of New Hampshire.

The researchers found that patients who are retired and/or disabled, working part time, or working full time are much more likely to be placed on a transplant waiting list than unemployed patients. They also are more likely to receive a transplant once placed on the list than unemployed patients. Finally, those who work full time are most likely to be both added to the transplant list and receive a kidney transplant.

The research was conducted by Woodward and researchers at the University of Pittsburgh Medical Center, University of Massachusetts Memorial Medical Center, and the Transplant Institute at Beth Israel Deaconess Medical Center. The new research is presented in the journal Clinical Transplantation in the article "Recipient's unemployment restricts access to renal transplantation."

Researchers evaluated transplant waiting list information for nearly 430,000 patients in end-stage renal disease from the U.S. Renal Data System and the United Network for Organ Sharing. Researchers investigated the employment status of these patients in relation to the amount of time between being diagnosed with end-stage renal disease and being listed on the transplant list, and the amount of time from when the patient was listed to when s/he received a transplant.

Of the nearly 430,000 patients evaluated for a kidney transplant, about 54,000 were added to the list for a kidney transplant. And of those listed for a kidney transplant, nearly 22,000 actually received a kidney transplant.

Although this analysis did not identify why those who are unemployed experience faced restricted access to kidney transplantation, the authors suspect there may be many factors that contribute to the unwillingness of transplant centers to list and transplant poorly employed patients.

The researchers explain that a number of factors are considered when deciding to add someone to a transplant list and move forward with the transplant procedure, including whether the patient can afford the post-transplant medical care and immunosuppressive medications. This post-transplant medical care plays an important part in the success of the transplant and survival of the patient.

"A lack of employment can lead to limited financial resources for the patient and subsequent inadequate medical care following the transplant. Transplant centers have found that patients with limited financial resources have higher rates of noncompliance with post-transplant medical care. Because noncompliance with post-transplant care is a leading cause of rejection, infection, and death, transplant centers may be more hesitant about providing access to transplants to those with limited financial resources," Woodward says.

Insurance status also may play a key role in whether access to kidney transplants is restricted to patients who are unemployed or employed part time, many of whom who may not have insurance due to their employment status. Woodward says there is significant evidence to suggest that lack of health insurance can significantly contribute to noncompliance with post-transplant medical care requirements, which might be responsible for up to 35 percent of unsuccessful kidney transplants.

Those who rely only on Medicare also may experience restricted access to transplant services. According to the researchers, even though Medicare pays for a large portion of the cost of the required immunosuppressant medications, it does not cover non-immunosuppressant prescription drugs that transplant patients are more likely to require. As a result, many transplant centers require secondary, private insurance before a patient is considered for listing on the transplant list.

Finally, Woodward and his fellow researchers say that transplant centers could view employment status as a marker of mental and physical health status, education level, and perceived compliance by the patient with post-transplant care.

Woodward and his co-authors suggest that patients who are more likely to experience barriers to transplants based on employment status could benefit from increased interaction between patients, social workers, and other medical personnel, including case managers and financial specialists. The focus should be on continued employment and vocational rehabilitation, they said.
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The University of New Hampshire, founded in 1866, is a world-class public research university with the feel of a New England liberal arts college. A land, sea, and space-grant university, UNH is the state's flagship public institution, enrolling 12,200 undergraduate and 2,300 graduate students.

University of New Hampshire

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