Universal health care may not fully solve inequities in access to kidney transplantation
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A study conducted in the United Kingdom revealed that racial minorities and patients of lower socioeconomic status were less likely to be waitlisted for kidney transplantation, despite its universal health care system.
“The United Kingdom National Health Service was founded on the principle of delivering equitable health care on the basis of need and not the ability to pay, and it was ranked first on equity in a recent international health care comparison,” wrote Rishi Pruthi, PhD, of Guy’s and St. Thomas’ National Health Service Foundation Trust in London, and colleagues. “Equity is a key consideration for assessing the pathway to kidney transplantation for patients with [end-stage kidney disease] ESKD.”
The researchers contended that although the United Kingdom has developed national clinical practice guidelines for transplant assessment, evidence suggests that certain patients (namely, ethnic minorities and those of lower socioeconomic status) still have a higher incidence of ESKD and reduced access to transplantation. According to the researchers, it remains unknown whether the disparities exist because these patient groups have a higher comorbidity burden or if specific center practices play a role.
“Studies to date have been limited in their ability to examine these factors due to their retrospective design and use of routine and limited registry data,” they wrote.
To further investigate whether equity exists in transplantation with universal health care, the researchers conducted a prospective, observational cohort study including all 71 kidney centers in the United Kingdom, considering both preemptive listing (2,676 patients) and listing within 2 years of starting dialysis (1,970 patients). Adjustments were made for patient-specific factors and center practice patterns.
Researchers determined the interquartile range across centers to be 6% to 33% for preemptive listing and 25% to 40% for listing after dialysis initiation.
Specific patient factors were found to be associated with a lower likelihood of being listed. These factors included older age, most comorbidities, BMI greater than 35 kg/m2 and not having seen a nephrologist within a year of renal replacement therapy initiation.
Lower socioeconomic status — as defined by living in rented/housing association accommodation, lack of car ownership and being long-term sick/disabled or retired from paid work vs. full-time/part-time employment — was also associated with reduced access to transplantation.
Regarding race, results showed Asian (odds ratio = 0.49) and black (OR = 0.43) patients both had reduced access to preemptive listing though, the researchers noted, Asian patients had a higher likelihood of being listed after starting dialysis (OR = 1.42).
“Further research is needed to understand the causal pathways between socioeconomic status and listing for transplantation, including the role of health literacy in influencing access to transplantation,” Pruthi said in a related press release.
After reviewing the findings, Meera N. Harhay, MD, of Drexel University in Philadelphia, and Patrick B. Mark, MD, of the University of Glasgow in the United Kingdom, argued that barriers to transplantation can persist regardless of universal health care coverage.
In an accompanying editorial, they suggested that “identifying and mitigating many other pervasive factors that prevent our most vulnerable patients from receiving the optimal treatments for ESKD,” is especially timely given the goals of Advancing American Kidney Health.
“This knowledge should motivate the nephrology community to examine the equity implications of our processes to educate, evaluate and select kidney transplant candidates,” they wrote. “Although only health policy can ensure that the door to kidney transplantation is open for all patients who could benefit, equity in transplantation will only be achievable if we are also ready to clear the path beyond the door.” – by Melissa J. Webb
Disclosures: Pruthi reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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Pruthi R, et al. Clin J Am Soc Nephrol. 2020;doi:10.2215/CJN.11460919.
Harhay MN and Mark PB. Clin J Am Soc Nephrol. 2020;doi:10.2215/CJN.03000320.
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