Prominent Impact of Community Risk Factors on Kidney Transplant Candidate Processes and Outcomes

Numerous factors impact patients' health beyond traditional clinical characteristics. We evaluated the association of risk factors in kidney transplant patients' communities with outcomes prior to transplantation. The primary exposure variable was a community risk score (range 0–40) derived from multiple databases and defined by factors including prevalence of comorbidities, access and quality of healthcare, self‐reported physical and mental health and socioeconomic status for each U.S. county. We merged data with the Scientific Registry of Transplant Recipients (SRTR) and utilized risk‐adjusted models to evaluate effects of community risk for adult candidates listed 2004–2010 (n = 209 198). Patients in highest risk communities were associated with increased mortality (adjusted hazard ratio [AHR] = 1.22, 1.16–1.28), decreased likelihood of living donor transplantation (adjusted odds ratio [AOR] = 0.90, 0.85–0.94), increased waitlist removal for health deterioration (AHR = 1.36, 1.22–1.51), decreased likelihood of preemptive listing (AOR = 0.85, 0.81–0.88), increased likelihood of inactive listing (AOR = 1.49, 1.43–1.55) and increased likelihood of listing for expanded criteria donor kidneys (AHR = 1.19, 1.15–1.24). Associations persisted with adjustment for rural–urban location; furthermore the independent effects of rural–urban location were largely eliminated with adjustment for community risk. Average community risk varied widely by region and transplant center (median = 21, range 5–37). Community risks are powerful factors associated with processes of care and outcomes for transplant candidates and may be important considerations for developing effective interventions and measuring quality of care of transplant centers.     

Geographic Disparities in Liver Availability: Accidents of Geography,or Consequences of Poor Social Policy?

Recently, a redistricting proposal intended to equalize Model for End‐stage Liver Disease score at transplant recommended expanding liver sharing to mitigate geographic variation in liver transplantation. Yet, it is unclear whether variation in liver availability is arbitrary and a disparity requiring rectification or reflects differences in access to care. We evaluate the proposal's claim that organ supply is an “accident of geography” by examining the relationship between local organ supply and the uneven landscape of social determinants and policies that contribute to differential death rates across the United States. We show that higher mortality leading to greater availability of organs may in part result from disproportionate risks incurred at the local level. Disparities in public safety laws, health care infrastructure, and public funding may influence the risk of death and subsequent availability of deceased donors. These risk factors are disproportionately prevalent in regions with high organ supply. Policies calling for organ redistribution from high‐supply to low‐supply regions may exacerbate existing social and health inequalities by redistributing the single benefit (greater organ availability) of greater exposure to environmental and contextual risks (e.g. violent death, healthcare scarcity). Variation in liver availability may not be an “accident of geography” but rather a byproduct of disadvantage.     

Caring for Diverse and High-Risk Patients: Surgeon,Health System,and Patient Integration

Access and outcome disparities exist in hip and knee arthroplasty care. These disparities are associated with race, ethnicity, and social determinants of health such as income, housing, transportation, education, language, and health literacy. Additionally, medical comorbidities affecting postoperative outcomes are more prevalent in underresourced communities, which are more commonly communities of color.Navigating racial and ethnic differences in treating our patients undergoing hip and knee arthroplasty is necessary to reduce inequitable care. It is important to recognize our implicit biases and lessen their influence on our healthcare decision-making. Social determinants of health need to be addressed on a large scale as the current inequitable system disproportionally impacts communities of color.Patients with lower health literacy have a higher risk of postoperative complications and poor outcomes after hip and knee replacement. Low health literacy can be addressed by improving communication, reducing barriers to care, and supporting patients in their efforts to improve their own health.High-risk patients require more financial, physical, and mental resources to care for them, and hospitals, surgeons, and health insurance companies are often disincentivized to do so. By advocating for alternative payment models that adjust for the increased risk and take into account the increased perioperative work needed to care for these patients, surgeons can help reduce inequities in access to care.We have a responsibility to our patients to recognize and address social determinants of health, improve the diversity of our workforce, and advocate for improved access to care to decrease inequity and outcomes disparities in our field.     

Perception of Risk: A Poll of American Association of Hip and Knee Surgeons Members

BackgroundProviders of total hip and knee replacements are being judged regarding quality/cost by payers using competition-based performance measures with poor medical and no socioeconomic risk adjustment. Providers might assume that other providers shed risk and the perception of added risk can influence practice. A poll was collected to examine such perceptions.MethodsIn 2019 a poll was sent to the 2800 surgeon members of the American Association of Hip and Knee Surgeons using Survey Monkey while protecting respondent anonymity/confidentiality. The questions asked whether the perception of poorly risk-adjusted medical comorbidities and socioeconomic risk factors influence surgeons to selectively offer surgery.ResultsThere were 474 surgeon responses. Prior to elective total hip arthroplasty/total knee arthroplasty, 95% address modifiable risk factors; 52% require a body mass index <40, 64% smoking cessation, 96% an adequate hemoglobin A1C; 82% check nutrition; and 63% expect control of alcohol 2. Due to lack of socioeconomic risk adjustment, 83% reported feeling pressure to avoid/restrict access to patients with limited social support, specifically the following: Medicaid/underinsured, 81%; African Americans, 29%; Hispanics/ethnicities, 27%; and low socioeconomic status, 73%. Of the respondents, 93% predicted increased access to care with more appropriate risk adjustment.ConclusionCompetition-based quality/cost performance measures influence surgeons to focus on medical risk factors in offering lower extremity arthroplasty. The lack of socioeconomic risk adjustment leads to perceptions of added risk from such factors as well. This leads to marginal loss of access for patients within certain medical and socioeconomic classes, contributing to existing healthcare disparities. This represents an unintended consequence of competition-based performance measures.     

Bridging the Gap: Innovative Approaches to Continuing Education in Rural,Remote, and Isolated First Nation Communities

Access to education, communication, and support is essential for achieving and maintaining a skilled healthcare workforce. Delivering affordable and accessible continuing education for healthcare providers in rural, remote, and isolated First Nation communities is challenging due to barriers such as geography, isolation, costs, and staff shortages. The innovative use of technology, such as on‐line courses and webinars, will be presented as a highly effective approach to increase access to continuing education for healthcare providers in these settings. A case study will be presented demonstrating how a national, not‐for‐profit health care organization has partnered with healthcare providers in these communities to support care at the local level through various technology‐based knowledge exchange activities.     

The impact of social determinants of health on the overall wellbeing of children: A review for the pediatric surgeon

Disparities in health care access, quality, and outcomes for pediatric patients, and their relationship to race and socioeconomic status (SES) have been extensively documented. The underlying causes behind such disparities have been less carefully studied, as clinicians and researchers often fail to look past immutable features such as race, into modifiable factors like social determinants of health (SDOH). A child's environment affects their patterns of social engagement, sense of security, and overall well-being. Resources such as affordable housing, access to education, public safety, and availability of healthy foods and safe play spaces impact and enhance quality of life, and have significant influence on both health and health care outcomes. These upstream indicators are often unrecognized or misidentified as health concerns. Few pediatric surgery publications discuss SDOH and their effects on children. This paper aims to introduce the five domains of SDOH (economic stability, education, social and community context, health and healthcare, and neighborhood and built environment) along with strategies to identify and address needs in these domains from a provider, hospital, and health system's perspective. It is anticipated that this information will serve as a foundation for pediatric surgeons to understand and develop processes that ameliorate disparities related to SDOH and improve surgical outcomes and the well-being of all children.     

Towards Improving the Transfer of Care of Kidney Transplant Recipients

Kidney transplant recipients require specialized medical care and may be at risk for adverse health outcomes when their care is transferred. This document provides opinion‐based recommendations to facilitate safe and efficient transfers of care for kidney transplant recipients including minimizing the risk of rejection, avoidance of medication errors, ensuring patient access to immunosuppressant medications, avoidance of lapses in health insurance coverage, and communication of risks of donor disease transmission. The document summarizes information to be included in a medical transfer document and includes suggestions to help the patient establish an optimal therapeutic relationship with their new transplant care team. The document is intended as a starting point towards standardization of transfers of care involving kidney transplant recipients.     

Modest rates and wide variation in timely access to repeat kidney transplantation in the United States

Success of transplantation is not limited to initial receipt of a donor organ. Many kidney transplant recipients experience graft loss following initial transplantation and the benefits of expedited placement on the waiting list and retransplantation extend to this population. Factors associated with access to repeat transplantation may be unique given experience with the transplant process and prior viability as a candidate. We examined the incidence, risk factors, secular changes, and center‐level variation of preemptive relisting or transplantation (PRLT) for kidney transplant recipients in the United States with graft failure (not due to death) using Scientific Registry of Transplant Recipients data from 2007 to 2018 (n = 39 557). Overall incidence of PRLT was 15% and rates of relisting declined over time. Significantly lower PRLT was evident among patients who were African American and Hispanic, males, older, obese, publicly insured, had lower educational attainment, were diabetic, had longer dialysis time prior to initial transplant, shorter graft survival, longer distance to transplant center, and resided in distressed communities. There was significant variation in PRLT by center, median = 13%, 10th percentile = 6%, 90th percentile = 24%. Cumulatively, results indicate that despite prior access to transplantation, incidence of PRLT is modest with pronounced clinical, social, and center‐level sources of variation suggesting opportunities to improve preemptive care among patients with failing grafts.     

Satisfaction with access and quality of healthcare services for people with spinal cord injury living in the community

Objective: To identify barriers to access healthcare services and reveal determinants of satisfaction with healthcare services in people with chronic spinal cord injury (SCI).

Design: Cross-sectional survey.

Setting: Community setting in Switzerland.

Participants: People with chronic SCI.

Interventions: Non-applicable.

Outcome Measures: Questionnaire-based evaluation of availability and quality of healthcare services for secondary health conditions, satisfaction with fulfillment of healthcare needs, and preference for care from a hypothetical service provider with limited specialized SCI care expertise but in close proximity over comprehensive care from an existing specialized SCI center located at a greater distance.

Results: Close to three-quarter of participants (70%) indicated satisfaction with healthcare services received for SCI related health conditions. Elderly individuals (61+ years old) rated the availability and quality of healthcare 6% to 11% higher than younger individuals. The perceived fulfillment of healthcare needs was lower in people with incomplete paraplegia (odds ratio (OR) 2.11, 95%-credibility interval (CI) 1.18–3.84), chronic pain (OR 1.85, CI 1.12–3.08), insufficient access to long distance transportation (OR 5.81, CI 2.74–12.82), and longer travel distances to specialized SCI centers.

Conclusion: Perceived inadequateness of access to healthcare services was partly related to transportation barriers, suggesting that outreach services or support with transportation are possible solutions. People with incomplete paralysis and pain consistently rated the fulfillment of care needs associated with SCI less favorably, pointing to the need for enhanced advocacy for this vulnerable groups.     

Resilience in children and their parents enduring pediatric medical traumatic stress

Due to the general lack of familiarity with the concept in the medical field, resilience is rarely considered in pediatric medical traumas. Resilience is an ability that enables recovery after adversities such as traumas, surgeries, serious health problems, or social issues. Stress from medical traumas encompasses both the psychological and physical responses of children and their families. Lack of resilience in children with medical traumatic stress may contribute to poor adjustment, slow recovery, disruptive behaviors, and psychiatric disorders. Furthermore, persistent parental distress increases the child's risk of low resilience. Consequently, these patients and their parents require early identification. This is achievable using a common stress measure such as the Perceived Stress Scale. Moreover, health care providers can screen patients’ risks for low resilience, which include few social contacts, poor family functioning, and low cohesion among family members. Findings from the stress scale and screened risks could indicate the need for additional psychosocial support at the time of diagnosis of a serious illness, soon after injuries, and before and after operations. Such interventions can include decreasing distress, counseling children and their parents, and enabling strong connections to health care providers. Health care providers can help parents to minimize distress and adjust to their child's illness, thereby supporting the child's resilience, adjustment, and recovery.     

Two years after lockdown: reviewing the effects of COVID‐19 on health services and support for adolescents living with HIV in South Africa

IntroductionSouth Africa''s progress towards the 95‐95‐95 goals has been significantly slower among adolescents living with HIV (ALHIV), among whom antiretroviral therapy (ART) adherence, retention in care and viral suppression remain a concern. After 2 years of living with COVID‐19, it is important to examine the direct and indirect effects of the pandemic on healthcare resources, access to HIV services and availability of support structures, to assess their impact on HIV care for ALHIV.DiscussionThe COVID‐19 response in South Africa has shifted healthcare resources towards combatting COVID‐19, affecting the quality and availability of HIV services—especially for vulnerable populations, such as ALHIV. The healthcare system''s response to COVID‐19 has threatened to diminish fragile gains in engaging ALHIV with HIV services, especially as this group relies on overburdened public health facilities for their HIV care. Reallocation of limited health resources utilized by ALHIV disrupted healthcare workers’ capacity to form and maintain therapeutic relationships with ALHIV and monitor ALHIV for ART‐related side effects, treatment difficulties and mental health conditions, affecting their ability to retain ALHIV in HIV care. Prevailing declines in HIV surveillance meant missed opportunities to identify and manage opportunistic infections and HIV disease progression in adolescents. “Lockdown” restrictions have limited access to healthcare facilities and healthcare workers for ALHIV by reducing clinic appointments and limiting individual movement. ALHIV have had restricted access to social, psychological and educational support structures, including national feeding schemes. This limited access, coupled with reduced opportunities for routine maternal and sexual and reproductive health services, may place adolescent girls at greater risk of transactional sex, child marriages, unintended pregnancy and mother‐to‐child HIV transmission.ConclusionsAdolescent HIV care in South Africa is often overlooked; however, ART adherence among ALHIV in South Africa is particularly susceptible to the consequences of a world transformed by COVID‐19. The current structures in place to support HIV testing, ART initiation and adherence have been reshaped by disruptions to health structures, new barriers to access health services and the limited available education and psychosocial support systems. Reflecting on these limitations can drive considerations for minimizing these barriers and retaining ALHIV in HIV care.     

Pandemics and maternal health: the indirect effects of COVID-19

Infectious diseases can directly affect women and men differently. During the COVID-19 pandemic, higher case fatality rates have been observed in men in most countries. There is growing evidence, however, that while organisational changes to healthcare delivery have occurred to protect those vulnerable to the virus (staff and patients), these may lead to indirect, potentially harmful consequences, particularly to vulnerable groups including pregnant women. These encompass reduced access to antenatal and postnatal care, with a lack of in-person clinics impacting the ability to screen for physical, psychological and social issues such as elevated blood pressure, mental health issues and sex-based violence. Indirect consequences also encompass a lack of equity when considering the inclusion of pregnant women in COVID-19 research and their absence from vaccine trials, leading to a lack of safety data for breastfeeding and pregnant women. The risk-benefit analysis of these changes to healthcare delivery remains to be fully evaluated, but the battle against COVID-19 cannot come at the expense of losing existing quality standards in other areas of healthcare, especially for maternal health.     

Health-related quality of life,uncertainty and coping strategies in solid organ transplant recipients during shielding for the COVID-19 pandemic

Strict isolation of vulnerable individuals has been a strategy implemented by authorities to protect people from COVID-19. Our objective was to investigate health-related quality of life (HRQoL), uncertainty and coping behaviours in solid organ transplant (SOT) recipients during the COVID-19 pandemic. A cross-sectional survey of adult SOT recipients undergoing follow-up at our institution was performed. Perceived health status, uncertainty and coping strategies were assessed using the EQ-5D-5L, Short-form Mishel Uncertainty in Illness Scale (SF-MUIS) and Brief Cope, respectively. Interactions with COVID-19 risk perception, access to health care, demographic and clinical variables were assessed. The survey was completed by 826 of 3839 (21.5%) invited participants. Overall, low levels of uncertainty in illness were reported, and acceptance was the major coping strategy (92%). Coping by acceptance, feeling protected, self-perceived susceptibility to COVID-19 were associated with lower levels of uncertainty. Health status index scores were significantly lower for those with mental health illness, compromised access to health care, a perceived high risk of severe COVID-19 infection and higher levels of uncertainty. A history of mental health illness, risk perceptions, restricted healthcare access, uncertainty and coping strategies was associated with poorer HRQoL in SOT recipients during strict isolation. These findings may allow identification of strategies to improve HRQoL in SOT recipients during the pandemic.     

Palliative and end of life care in solid organ transplantation

Palliative care is an interprofessional approach that focuses on quality of life of patients who are facing life‐threatening illness. Palliative care is consistently associated with improvements in advance care planning, patient and caregiver satisfaction, quality of life, symptom burden, and lower healthcare utilization. Most transplant patients have advanced chronic disease, significant symptom burden, and mortality awaiting transplant. Transplantation introduces new risks including perioperative death, organ rejection, infection, renal insufficiency, and malignancy. Numerous publications over the last decade identify that palliative care is well‐suited to support these patients and their caregivers, yet access to palliative care and research within this population are lacking. This review describes palliative care and summarizes existing research supporting palliative intervention in advanced organ failure and transplant populations. A proposed model to provide palliative care in parallel with disease‐directed therapy in a transplant program has the potential to improve symptom burden, quality of life, and healthcare utilization. Further studies are needed to elucidate specific benefits of palliative care for this population. In addition, there is a tremendous need for education, specifically for clinicians, patients, and families, to improve understanding of palliative care and its benefits for patients with advanced disease.     

Knowledge, beliefs and attitudes of kidney transplant recipients regarding their risk of cancer

Aim: Despite an increased risk of cancer post transplant, little is known about the knowledge, beliefs of and attitudes to cancer and its prevention among kidney transplant recipients. This study aims to explore these beliefs and attitudes, to better understand patient motives and potential barriers to early detection of cancer. Methods: Semi‐structured interviews were conducted with 14 kidney and eight kidney–pancreas transplant recipients based at a single transplant centre in Sydney, Australia, between October 2009 and February 2010. Results: Thematic data analysis identified four major themes: (1) skin cancer‐focused: participants were generally only aware about their increased risk of skin cancer and available prevention strategies for that cancer alone; (2) limited awareness: participants knew little about their excess risk for non‐skin cancers and possible preventative and screening strategies; (3) fear of cancer: cancer fears were heightened by prior experiences; some felt vulnerable to cancer and perceived that cancer outcomes were worse than kidney disease; and (4) prioritizing present health issues: participants believed cancer was not imminent and had limited capacity to absorb information about long‐term risks, particularly as current health concerns appeared pressing and important. Conclusion: Awareness of increased cancer risk and cancer screening among kidney transplant recipients is focused narrowly on skin cancer, with limited awareness for other cancers. Recipients prioritized current health issues rather than future risks to health such as cancer. Transplant care providers should provide evidence‐based information on cancer risk and screening, being sensitive to the timing and needs of the patient. Improved knowledge may empower patients to minimize their risk of cancer by participating in screening and cancer prevention programmes.     

An overlooked majority: HIV-positive gay men who smoke

Therapeutic advances have dramatically improved health outcomes and life expectancy among persons living with HIV, but gains in life expectancy achieved by antiretroviral therapy may be mitigated by other health risk behaviours. HIV-positive gay men are especially at-risk for smoking and its adverse health risks. This scoping review summarizes evidence related to HIV and smoking, paying particular attention to gay men's masculinities as a means of providing direction for tailored tobacco cessation interventions for this vulnerable group. HIV-positive gay men face challenges with managing a complex disease and its psychological and social issues require tailored tobacco cessation interventions cognisant of the diverse social contexts in which they live. Although tobacco cessation intervention research among these men is limited, we make some recommendations to guide researchers and health care providers who work with these men.     

Psychosocial factors in people with chronic kidney disease prior to renal replacement therapy

Increasing evidence implicates psychosocial factors including depression, anxiety, perceived social support and health‐related quality of life in the pathophysiology of various chronic diseases. Research examining the psychosocial aspects of kidney disease has focussed predominantly on depressive disorders in dialysis patients where they are independently associated with increased risk of mortality and poor health‐related quality of life. In contrast, studies examining the influence of psychosocial factors in people with chronic kidney disease (CKD) prior to the initiation of renal replacement therapy are sparse. Limited data indicate that clinical depression and depressive symptoms are common and may independently predict progression to dialysis, hospitalization and death. In contrast, the influence of anxiety disorders, lower perceived social support and impaired health‐related quality of life on the clinical course of CKD have received little attention. Large‐scale prospective cohort studies are needed to clarify the burden and prognostic impact of these factors in this vulnerable population. Given the escalating burden of CKD worldwide examining the role of these potentially modifiable risk factors is crucial. Identifying and implementing targeted interventions in order to prevent or delay the progression of CKD and improve quality of life will be a major challenge.     

Innovations in the Assessment of Transplant Center Performance: Implications for Quality Improvement

Continuous quality improvement efforts have become a central focus of leading health care organizations. The transplant community has been a pioneer in periodic review of clinical outcomes to ensure the optimal use of limited donor organs. Through data collected from the Organ Procurement and Transplantation Network (OPTN) and analyzed by the Scientific Registry of Transplant Recipients (SRTR), transplantation professionals have intermittent access to specific, accurate and clinically relevant data that provides information to improve transplantation. Statistical process control techniques, including cumulative sum charts (CUSUM), are designed to provide continuous, real-time assessment of clinical outcomes. Through the use of currently collected data, CUSUMs can be constructed that provide risk-adjusted program-specific data to inform quality improvement programs. When retrospectively compared to currently available data reporting, the CUSUM method was found to detect clinically significant changes in center performance more rapidly, which has the potential to inform center leadership and enhance quality improvement efforts.     

Recipient-Based Approach to Tailoring Immunosuppression in Liver Transplantation

Improvements in the field of transplant immunosuppression (IS) have led to significant advances in long-term survival of liver transplant recipients. Despite this progress, survival rates vary depending on recipient, donor and/or perioperative factors. Tailoring IS based on recipient factors is of growing interest among health care providers involved in the care of organ transplant recipients. To date there is no consensus document addressing individualized IS therapy for liver transplant recipients. This review will discuss the information available on the effect of the various IS drugs on recipient-based factors such as age, ethnicity, and liver disease etiology.     

Creating Musculoskeletal Programs for Culturally Diverse,Underserved Communities: a Community-Based Participatory Research Survey

Background

Arthritis and other musculoskeletal diseases are the most prevalent health conditions in the USA, causing enormous financial and social burdens, especially in underserved communities. Targeted care and prevention programs are urgently needed.

Questions/Purposes

Within an overall goal of revealing health disparities, the questionnaire explored (1) the use of and access to healthcare, (2) the factors affecting quality of life, and (3) the levels of provider–patient communication.

Methods

A New York City musculoskeletal hospital conducted a community health needs survey among its diverse ethnic/racial communities. A 39-item questionnaire was administered online, by mail, and in person (in English, Spanish, and Chinese). Answers were analyzed in terms of sociodemographics, to define health disparities within a total sample and two subsamples.

Results

In the total sample, respondents were 60% White, 16% Black, 14% Hispanic/Latino, and 11% Asian, mostly female, and aged 50 to 79. More than 17% of the total sample indicated they could not access a healthcare provider when needed. Poor nutrition and lack of physical activity were large areas of concern, as were falls and poor self-reported health status. Nearly all respondents said they took steps to communicate with their healthcare providers. Dramatic health disparities were found between Whites and non-Whites (e.g., non-Whites were most likely to rate their health poorly, consider their diet fair or poor, lack health insurance, and be unable to access a healthcare provider).

Conclusion

The findings are being used to further refine, develop, and expand the hospital’s community programs, especially for culturally diverse and underserved communities.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-014-9413-9) contains supplementary material, which is available to authorized users.