title: The association of community health indicators with outcomes for kidney transplant recipients in the United States.
abstract: OBJECTIVE
  To evaluate the association of community health indicators with outcomes for kidney transplant recipients.
  
  
  METHODS
  Retrospective observational cohort study using multivariable Cox proportional hazards models.
  
  
  METHODS
  Transplant recipients in the United States from the Scientific Registry of Transplant Recipients merged with health indicators compiled from several national databases and the Centers for Disease Control and Prevention, including the National Center for Health Statistics, the Behavioral Risk Factor Surveillance System, and the National Center for Chronic Disease Prevention and Health Promotion.
  
  
  METHODS
  A total of 100 164 living and deceased donor adult (aged 18 years) kidney transplant recipients who underwent a transplant between January 1, 2004, and December 31, 2010.
  
  
  METHODS
  Risk-adjusted time to posttransplant mortality and graft loss.
  
  
  RESULTS
  Multiple health indicators from recipients' residence were independently associated with outcomes, including low birth weight, preventable hospitalizations, inactivity rate, and smoking and obesity prevalence. Recipients in the highest-risk counties were more likely to be African American (adjusted odds ratio, 1.59, 95% CI, 1.51-1.68), to be younger (aged 18-39 years; 1.46; 1.32-1.60), to have lower educational attainment (<high school; 1.84; 1.62-2.08), and to have public insurance (1.46; 1.38-1.54). Proportions of recipients from higher-risk counties varied dramatically by center and region. There was an independent graded effect between health indicators and posttransplant mortality, including notable hazard associated with the highest-risk counties (adjusted hazard ratio, 1.26; 95% CI, 1.13-1.40).
  
  
  CONCLUSIONS
  In a national cohort of patients undergoing complex medical procedures, health indicators from patients' communities are strong independent predictors of all-cause mortality. Findings highlight the importance of community conditions for risk stratification of patients and development of individualized treatment protocols. Findings also demonstrate that standard risk adjustment does not capture important factors that may affect unbiased performance evaluations of transplant centers.
authors.affiliation: Departments of Quantitative Health Sciences, Case Western University, Cleveland, OH 44195, USA. scholdj@ccf.org
authors.forename: Jesse D
authors.initials: JD
authors.lastname: Schold
authors.forename: Laura D
authors.initials: LD
authors.lastname: Buccini
authors.forename: Michael W
authors.initials: MW
authors.lastname: Kattan
authors.forename: David A
authors.initials: DA
authors.lastname: Goldfarb
authors.forename: Stuart M
authors.initials: SM
authors.lastname: Flechner
authors.forename: Titte R
authors.initials: TR
authors.lastname: Srinivas
authors.forename: Emilio D
authors.initials: ED
authors.lastname: Poggio
authors.forename: Richard
authors.initials: R
authors.lastname: Fatica
authors.forename: Liise K
authors.initials: LK
authors.lastname: Kayler
authors.forename: Ashwini R
authors.initials: AR
authors.lastname: Sehgal
mesh_terms: D000328:Adult; D005260:Female; D006305:Health Status Indicators; D006801:Humans; D016030:Kidney Transplantation / Q000592:standards / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D016016:Proportional Hazards Models; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012959:Socioeconomic Factors; D014481:United States