VA National Transplant System Shows No Racial/Ethnic Disparities in Evaluating Veterans for Kidney Transplant

BACKGROUND:
End-Stage Kidney Disease (ESKD) disproportionately affects racial/ethnic minority populations, with an incidence rate of 3.4 and 1.5 times greater in the African-American and Hispanic populations, respectively, compared to non-Hispanic whites. However, minority populations are substantially less likely to undergo kidney transplantation (KT) – the optimal treatment for ESKD. This longitudinal study examined VA patients of diverse racial/ethnic backgrounds with ESKD who underwent the evaluation process for KT. Investigators identified 602 Veterans (African Americans, n=199; non-Hispanic whites, n=271; and other minorities, n=132) who underwent initial evaluation for KT at the four national VA kidney transplant centers, serving all geographic regions of the U.S., from 2010 to 2014. Telephone interviews were conducted to determine whether, after controlling for medical factors (e.g., health history, comorbidities), differences in acceptance time for transplant were explained by patients' demographic, cultural (e.g., medical mistrust, perceived discrimination, religious objections), psychosocial (e.g., emotional distress, social support, self-esteem), or transplant knowledge factors.

FINDINGS:

• In comparing African American Veterans with white Veterans and other minority Veterans, the VA National Transplant System did not exhibit the racial/ethnic disparities in evaluation for kidney transplant that have been found in non-VA transplant centers. Moreover, VA kidney transplant centers are successfully bringing ESKD patients through the evaluation process without race disparities at a time when non-VA transplant centers are unable to do so, while achieving a median time to complete evaluation similar to other published rates in non-VA settings.
• Factors that predicted an increased likelihood of KT acceptance included: younger age, fewer comorbidities, being married, having private health insurance, and moderate to greater levels of depression. Other factors (i.e., transplant center location, preference for a living or deceased donor) were significant but showed a complex relationship with acceptance.

IMPLICATIONS:

• These results suggest that specific characteristics of the VA heatlhcare system and/or Veterans may play a role in mitigating disparities.

LIMITATIONS:

• By focusing only on Veterans who presented for evaluation at a designated VA kidney transplant center, investigators were unable to evaluate the important issues of disparities in referral for transplantation or the initial pre-evaluation performed by centralized chart review.
• While investigators examined many potential predictors of completing the KT evaluation, there are predictors (i.e., time from diagnosis to referral, or county of residence) that were not measured.

AUTHOR/FUNDING INFORMATION:
This study was partly funded by HSR&D (IAA 06-220). Drs. Myaskovsky, Pleis, Chang, and Switzer are part of HSR&D's Center for Health Equity Research and Promotion (CHERP), Pittsburgh, PA.

Freeman M, Pleis J, Bornemann K, Croswell E, Dew M, Chang C-C, Switzer G, Langone A, Mittalhenkle A, Saha S, Ramkumar M, Flohr J, Thomas C, and Myaskovsky L. Has the Department of Veterans Affairs Found a Way to Avoid Racial Disparities in the Evaluation Process for Kidney Transplantation? Transplantation. August 1, 2016; ePub ahead of print.