Hypothesis challenged: patient preferences do not explain racial differences in kidney transplant access

November 24, 1999

Study finds blacks 20 percent less likely than whites to be referred for kidney transplant even when desired

BOSTON-November 22, 1999-Harvard researchers in the November 25 New England Journal of Medicine report both a racial disparity in access to kidney transplantation, and that this disparity was not the result of patient preference, a potential hypothesis put forth to explain the well-documented racial differences in access to effective medical procedures.

"While our analysis showed that black patients were slightly less likely than white patients to want a transplant, this difference did not account for the lack of referrals for transplant procedures," says John Ayanian, MD, MPP, assistant professor of medicine and of health care policy at Harvard Medical School and Brigham and Women's Hospital.

Previous studies have shown that black patients are less likely than white patients to undergo many effective procedures that might improve health and quality of life, including kidney transplantation, coronary-artery bypass surgery and angioplasty, mammography, and total knee and hip replacement. Despite repeated studies proving such disparities in care, few large-scale studies have tried to determine the underlying causes, such as bias or patient preference.

"To improve access to treatment options, health care providers and policy makers need to know the factors creating barriers to care," says Ayanian. "This study begins to address this need by tackling the hypothesis that patient preference is a root cause of the racial differences we see in treatment options selected."

The renal transplantation model was chosen for this study because unlike candidates for most other major medical procedures, patients with kidney disease can be reliably identified and located. Further, transplantation is an attractive treatment option because it improves the quality of life and is less costly than dialysis. The study revealed that:

Dr. Ayanian and the studys co-authors, Paul Cleary, PhD, professor of health care policy at Harvard Medical School, Joel Weissman, PhD, assistant professor of medicine at Massachusetts General Hospital, and Arnold Epstein, MD, professor of medicine and health policy and management at the Harvard School of Public Health and Brigham and Women's Hospital, conclude from the study that physicians must ensure that black patients eligible for kidney transplantation are more fully informed about their treatment options and referred for evaluation.

The study, funded by the Robert Wood Johnson Foundation, was conducted with the assistance of four regional End-Stage Renal Disease Networks and the United Network for Organ Sharing. The authors surveyed 1392 patients with end-stage renal disease and reviewed the medical records of 1,169 of them in Alabama, southern California, Michigan, Maryland, Virginia, and the District of Columbia. Patients included in the study were between the ages of 18 and 54 years and had begun dialysis during the period from May 1996 through June 1997. Patients were contacted approximately 10 months after they started dialysis therapy to allow sufficient time for them to be accustomed to the treatment.

Harvard Medical School

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