title: Prominent impact of community risk factors on kidney transplant candidate processes and outcomes.
abstract: 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.
authors.affiliation: Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH; Center for Health Disparities, MetroHealth Medical Center and Case Western Reserve University, Cleveland, OH.
authors.forename: J D
authors.initials: JD
authors.lastname: Schold
authors.forename: E L G
authors.initials: EL
authors.lastname: Heaphy
authors.forename: L D
authors.initials: LD
authors.lastname: Buccini
authors.forename: E D
authors.initials: ED
authors.lastname: Poggio
authors.forename: T R
authors.initials: TR
authors.lastname: Srinivas
authors.forename: D A
authors.initials: DA
authors.lastname: Goldfarb
authors.forename: S M
authors.initials: SM
authors.lastname: Flechner
authors.forename: J R
authors.initials: JR
authors.lastname: Rodrigue
authors.forename: J D
authors.initials: JD
authors.lastname: Thornton
authors.forename: A R
authors.initials: AR
authors.lastname: Sehgal
mesh_terms: D000328:Adult; D000368:Aged; D003153:Community Health Services / Q000600:supply & distribution*; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D007676:Kidney Failure, Chronic / Q000208:ethnology; D016030:Kidney Transplantation / Q000401:mortality*; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D012307:Risk Factors; D012424:Rural Population; D014019:Tissue Donors; D016896:Treatment Outcome; D014505:Urban Population; D014850:Waiting Lists / Q000401:mortality
keywords: Access to transplantation; comorbidity; kidney transplantation; living donor transplantation; preemptive; risk factors; socioeconomic status; waiting list; waitlist mortality
references.citation: Am J Transplant. 2010 Mar;10(3):472-6
references.pmid: 20055801
references.citation: Nephrol Dial Transplant. 2012 Mar;27(3):1239-45
references.pmid: 22036942
references.citation: JAMA. 2009 Apr 22;301(16):1681-90
references.pmid: 19383959
references.citation: Am J Transplant. 2006;6(5 Pt 2):1228-42
references.pmid: 16613598
references.citation: Am J Transplant. 2005 Apr;5(4 Pt 2):850-61
references.pmid: 15760413
references.citation: Am J Public Health. 2011 Aug;101(8):1456-65
references.pmid: 21680937
references.citation: Ann N Y Acad Sci. 1999;896:347-9
references.pmid: 10681918
references.citation: Kidney Int. 2006 Jan;69(2):343-9
references.pmid: 16408125
references.citation: Nephrol Dial Transplant. 2007 Mar;22(3):891-8
references.pmid: 17172252
references.citation: Clin J Am Soc Nephrol. 2009 Jul;4(7):1239-45
references.pmid: 19541814
references.citation: BMC Nephrol. 2012 Oct 12;13:135
references.pmid: 23057616
references.citation: Am J Transplant. 2013 Jan;13(1):67-75
references.pmid: 23279681
references.citation: N Engl J Med. 2011 Oct 20;365(16):1509-19
references.pmid: 22010917
references.citation: Am J Transplant. 2009 Mar;9(3):506-16
references.pmid: 19191763
references.citation: Am J Transplant. 2012 Feb;12(2):358-68
references.pmid: 22233181
references.citation: Nephrol Dial Transplant. 2012 Aug;27(8):3321-9
references.pmid: 22422867
references.citation: Contemp Clin Trials. 2012 Jul;33(4):811-8
references.pmid: 22510472
references.citation: Am J Transplant. 2010 Apr;10(4):802-809
references.pmid: 20148808
references.citation: JAMA. 2008 Jan 9;299(2):202-7
references.pmid: 18182602
references.citation: Am J Transplant. 2008 Mar;8(3):647-57
references.pmid: 18294161
references.citation: Med Care. 2009 Feb;47(2):146-53
references.pmid: 19169114
references.citation: Clin Transplant. 2009 Nov-Dec;23(6):778-83
references.pmid: 20447183
references.citation: Epidemiology. 1997 Jan;8(1):42-7
references.pmid: 9116094
references.citation: BMJ. 1997 Jun 14;314(7096):1724-7
references.pmid: 9185498
references.citation: Am J Transplant. 2003 Jul;3(7):775-85
references.pmid: 12814469
references.citation: Clin J Am Soc Nephrol. 2010 Dec;5(12):2276-88
references.pmid: 20798250
references.citation: Clin J Am Soc Nephrol. 2006 Mar;1(2):313-22
references.pmid: 17699222
references.citation: Am J Transplant. 2006 Jul;6(7):1689-95
references.pmid: 16827872
references.citation: Semin Dial. 2005 Nov-Dec;18(6):499-504
references.pmid: 16398713
references.citation: Am J Transplant. 2010 Sep;10(9):2008-16
references.pmid: 20645941
references.citation: JAMA. 1998 Jun 3;279(21):1703-8
references.pmid: 9624022
references.citation: Transplantation. 2003 Jun 27;75(12):1940-5
references.pmid: 12829891
references.citation: Arch Surg. 2012 Jun;147(6):520-6
references.pmid: 22351876
references.citation: J Am Soc Nephrol. 2010 Jul;21(7):1192-9
references.pmid: 20558541
references.citation: Milbank Q. 1998;76(3):341-73, 304
references.pmid: 9738167
references.citation: JAMA. 2004 Mar 10;291(10):1238-45
references.pmid: 15010446
references.citation: J Epidemiol Community Health. 2003 Mar;57(3):186-99
references.pmid: 12594195
references.citation: Am J Transplant. 2008 Dec;8(12):2636-46
references.pmid: 19032227
references.citation: Am J Public Health. 2011 Jan;101(1):79-86
references.pmid: 20299643
references.citation: Transplantation. 2003 Nov 15;76(9):1389-94
references.pmid: 14627922
references.citation: Circulation. 2005 Mar 15;111(10):1257-63
references.pmid: 15769766
references.citation: Transplantation. 2008 Dec 27;86(12):1678-83
references.pmid: 19104404
references.citation: J Am Soc Nephrol. 2009 Jun;20(6):1333-40
references.pmid: 19339381
references.citation: N Engl J Med. 2001 Mar 8;344(10):726-31
references.pmid: 11236776
references.citation: J Am Soc Nephrol. 2000 Apr;11(4):753-759
references.pmid: 10752535
references.citation: Ann Intern Med. 2012 Apr 3;156(7):483-90
references.pmid: 22473435
references.citation: Transplantation. 2001 Jun 27;71(12):1752-7
references.pmid: 11455254
references.citation: Am J Transplant. 2007 Feb;7(2):394-401
references.pmid: 17173659
references.citation: Am J Nephrol. 2013;37(3):274-80
references.pmid: 23548738