title: If you can't comply with dialysis, how do you expect me to trust you with transplantation? Australian nephrologists' views on indigenous Australians' 'non-compliance' and their suitability for kidney transplantation.
abstract: BACKGROUND
  Indigenous Australians suffer markedly higher rates of end-stage kidney disease (ESKD) but are less likely than their non-Indigenous counterparts to receive a transplant. This difference is not fully explained by measurable clinical differences. Previous work suggests that Indigenous Australian patients may be regarded by treating specialists as 'non-compliers', which may negatively impact on referral for a transplant. However, this decision-making is not well understood. The objectives of this study were to investigate: whether Indigenous patients are commonly characterised as 'non-compliers'; how estimations of patient compliance factor into Australian nephrologists' decision-making about transplant referral; and whether this may pose a particular barrier for Indigenous patients accessing transplants.
  
  
  METHODS
  Nineteen nephrologists, from eight renal units treating the majority of Indigenous Australian renal patients, were interviewed in 2005-06 as part of a larger study. Thematic analysis was undertaken to investigate how compliance factors in specialists' decision-making, and its implications for Indigenous patients' likelihood of obtaining transplants.
  
  
  RESULTS
  Specialists commonly identified Indigenous patients as both non-compliers and high-risk transplant candidates. Definition and assessment of 'compliance' was neither formal nor systematic. There was uncertainty about the value of compliance status in predicting post-transplant outcomes and the issue of organ scarcity permeated participants' responses. Overall, there was marked variation in how specialists weighed perceptions of compliance and risk in their decision-making.
  
  
  CONCLUSIONS
  Reliance on notions of patient 'compliance' in decision-making for transplant referral is likely to result in continuing disadvantage for Indigenous Australian ESKD patients. In the absence of robust evidence on predictors of post-transplant outcomes, referral decision-making processes require attention and debate.
authors.affiliation: The George Institute for Global Health, Sydney, Australia. kanderson@george.org.au
authors.forename: Kate
authors.initials: K
authors.lastname: Anderson
authors.forename: Jeannie
authors.initials: J
authors.lastname: Devitt
authors.forename: Joan
authors.initials: J
authors.lastname: Cunningham
authors.forename: Cilla
authors.initials: C
authors.lastname: Preece
authors.forename: Meg
authors.initials: M
authors.lastname: Jardine
authors.forename: Alan
authors.initials: A
authors.lastname: Cass
mesh_terms: D001291:Attitude of Health Personnel; D001315:Australia; D003657:Decision Making; D006303:Health Services, Indigenous / Q000706:statistics & numerical data*; D054625:Healthcare Disparities / Q000592:standards; D006801:Humans; D007407:Interviews as Topic; D007676:Kidney Failure, Chronic / Q000601:surgery*; D016030:Kidney Transplantation / Q000523:psychology; D009398:Nephrology / Q000592:standards; D010043:Outcome and Process Assessment, Health Care / Q000379:methods; D010342:Patient Acceptance of Health Care / Q000523:psychology / Q000706:statistics & numerical data; D010349:Patient Compliance / Q000523:psychology; D010820:Physicians / Q000523:psychology*; D040841:Resource Allocation; D011795:Surveys and Questionnaires; D000078329:Workforce