Racial disparities in access to renal transplantation - Clinically appropriate or due to underuse or overuse?

被引:486
作者
Epstein, AM
Ayanian, JZ
Keogh, JH
Noonan, SJ
Armistead, N
Cleary, PD
Weissman, JS
David-Kasdan, JA
Carlson, D
Fuller, J
Marsh, D
Conti, RM
机构
[1] Harvard Univ, Sch Publ Hlth, Dept Hlth Policy & Management, Boston, MA 02115 USA
[2] Brigham & Womens Hosp, Div Gen Med, Sect Hlth Serv & Policy Res, Boston, MA 02115 USA
[3] Harvard Univ, Sch Med, Dept Hlth Care Policy, Boston, MA 02115 USA
[4] CliGnosis, Boston, MA USA
[5] Midatlantic Renal Coalit, Midlothian, VA USA
[6] Massachusetts Gen Hosp, Inst Hlth Policy, Boston, MA 02114 USA
[7] Renal Network Upper Midwest, St Paul, MN USA
[8] Network 8, Jackson, MS USA
[9] So Calif Renal Dis Council, Hollywood, CA USA
关键词
D O I
10.1056/NEJM200011233432106
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
Background: Despite abundant evidence of racial disparities in the use of surgical procedures, it is uncertain whether these disparities reflect racial differences in clinical appropriateness or overuse or underuse of care. Methods: We performed a literature review and used an expert panel to develop criteria for determining the appropriateness of renal transplantation for patients with end-stage renal disease. Using data from five states and the District of Columbia on patients who had started to undergo dialysis in 1996 or 1997, we selected a random sample of 1518 patients (age range, 18 to 54 years), stratified according to race and sex. We classified the appropriateness of patients as candidates for transplantation and analyzed data on rates of referral to a transplantation center for evaluation, placement on a waiting list, and receipt of a transplant according to race. Results: Black patients were less likely than white patients to be rated as appropriate candidates for transplantation according to appropriateness criteria based on expert opinion (71 blacks [9.0 percent] vs. 152 whites [20.9 percent]) and were more likely to have had incomplete evaluations (368 [46.5 percent] vs. 282 [38.8 percent], P<0.001 for the overall chi-square). Among patients considered to be appropriate candidates for transplantation, blacks were less likely than whites to be referred for evaluation, according to the chart review (90.1 percent vs. 98.0 percent, P=0.008), to be placed on a waiting list (71.0 percent vs. 86.7 percent, P=0.007), or to undergo transplantation (16.9 percent vs. 52.0 percent, P<0.001). Among patients classified as inappropriate candidates, whites were more likely than blacks to be referred for evaluation (57.8 percent vs. 38.4 percent), to be placed on a waiting list (30.9 percent vs. 17.4 percent), and to undergo transplantation (10.3 percent vs. 2.2 percent, P<0.001 for all three comparisons). Conclusions: Racial disparities in rates of renal transplantation stem from differences in clinical characteristics that affect appropriateness as well as from underuse of transplantation among blacks and overuse among whites. Reducing racial disparities will require efforts to distinguish their specific causes and the development of interventions tailored to address them. (N Engl J Med 2000;343:1537-44.) (C) 2000, Massachusetts Medical Society.
引用
收藏
页码:1537 / U8
页数:9
相关论文
共 40 条
  • [1] Barriers to cadaveric renal transplantation among blacks, women, and the poor
    Alexander, GC
    Sehgal, AR
    [J]. JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 1998, 280 (13): : 1148 - 1152
  • [2] RACIAL-DIFFERENCES IN THE USE OF REVASCULARIZATION PROCEDURES AFTER CORONARY ANGIOGRAPHY
    AYANIAN, JZ
    UDVARHELYI, IS
    GATSONIS, CA
    PASHOS, CL
    EPSTEIN, AM
    [J]. JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 1993, 269 (20): : 2642 - 2646
  • [3] The effect of patients' preferences on racial differences in access to renal transplantation
    Ayanian, JZ
    Cleary, PD
    Weissman, JS
    Epstein, AM
    [J]. NEW ENGLAND JOURNAL OF MEDICINE, 1999, 341 (22) : 1661 - 1669
  • [4] Rating the appropriateness of coronary angiography - Do practicing physicians agree with an expert panel and with each other?
    Ayanian, JZ
    Landrum, MB
    Normand, SLT
    Guadagnoli, E
    McNeil, BJ
    [J]. NEW ENGLAND JOURNAL OF MEDICINE, 1998, 338 (26) : 1896 - 1904
  • [5] HOW CORONARY ANGIOGRAPHY IS USED - CLINICAL DETERMINANTS OF APPROPRIATENESS
    CHASSIN, MR
    KOSECOFF, J
    SOLOMON, DH
    BROOK, RH
    [J]. JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 1987, 258 (18): : 2543 - 2547
  • [6] DOES INAPPROPRIATE USE EXPLAIN GEOGRAPHIC VARIATIONS IN THE USE OF HEALTH-CARE SERVICES - A STUDY OF 3 PROCEDURES
    CHASSIN, MR
    KOSECOFF, J
    PARK, RE
    WINSLOW, CM
    KAHN, KL
    MERRICK, NJ
    KEESEY, J
    FINK, A
    SOLOMON, DH
    BROOK, RH
    [J]. JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 1987, 258 (18): : 2533 - 2537
  • [7] Eggers P W, 1995, Health Care Financ Rev, V17, P89
  • [9] ELIXHAUSER A, 1994, AHCPR PUBL
  • [10] RACIAL-DIFFERENCES IN THE ELDERLY USE OF MEDICAL PROCEDURES AND DIAGNOSTIC-TESTS
    ESCARCE, JJ
    EPSTEIN, KR
    COLBY, DC
    SCHWARTZ, JS
    [J]. AMERICAN JOURNAL OF PUBLIC HEALTH, 1993, 83 (07) : 948 - 954