Healthcare Disparities and Need for Transplant in our Multicultural Communities

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1 Healthcare Disparities and Need for Transplant in our Multicultural Communities AMAT 20 th Annual Meeting September 19, 2012 Anil S. Paramesh, MD, FACS Associate Professor of Surgery and Urology Tulane University School of Medicine

2 Objectives Describe the disparities with disease prevalence Describe the disparities with organ donation Describe the disparities in organ transplant rates and success Describe how new legislation will affect transplant

3 Transplantation The process of transferring viable tissue from one body to another Perhaps one of the most exciting fields of medicine Definitely one of the most scrutinized!

4 What Do We Mean By Multicultural? Race Religion Ethnicity Geographic location Age Sex

5 So Has Transplant Gotten Better or Not? A little.. Factors to consider - Better techniques Better meds Sicker Patients, retransplants Worse organ donors

6 The Problem with ESRD Almost 1 out of every 5 people will be diagnosed with kidney disease Huge increases in demand for dialysis and transplant Inequalities in disease for race and economically disadvantaged populations

7 Inequalities in Disease Compared to Caucasians, ESRD is - 5x more likely in African Americans - 4x more likely in Native Americans/Alaskans - 3x more likely in Hispanics

8 Inequity in Transplant Genetic/tissue matching Rates of comorbidities Varying socioeconomic status Varying geographic organ donation rates Cultural attitudes towards donation and transplant Erroneous patient and healthcare provider beliefs

9 How Should Organ Allocation Work? Most Utility? Transplant pts that would have best survival Most Beneficent? Transplant pts that need it most

10 Utility Do not transplant pts with known risk factors Poor socioeconomic status Diabetics Older age Race?

11 Beneficence There are not enough organs for all. Sickest patient first! Heart Lung Liver Intestine Kidney (in progress)

12 How Are Organs Allocated?

13 Overall donation rates (per 100 eligible deaths), by DSA, 2009

14 Patients on Waiting List for Transplant

15 Transplants Performed Per Year

16 Religion and Organ Donation Most religions support organ donation. Viewed as an act of charity and love Individual decision

17 Religions and Organ Donation African Methodist Episcopal Assembly of God Catholicism Church of Christ, Scientist Greek Orthodox Conserv Evangelical Jehovah s Witnesses Lutheran Church Moravian Pentecostal Seventh Day Adventist Quakers Gypsies* Shintoism* Zoroastrianism* Amish Buddhism Christian Church Episcopal Hinduism Islam Judaism Mennonite Mormon Presbyterian Southern Baptist Convention Unitarian Universalist United Methodist United Church of Christ

18 Fact Minorities make up 52% of the organ transplant waiting list in this country

19 Why minority donors are needed Need for transplant is disproportionately high in some minorities African Americans, Hispanics and Asians have much higher incidence of diabetes and hypertension than Caucasians Initial studies show that AAs do better with AA organs Organs are not allocated by race, but by genetic matching. Hence minorities would match better if there were more minority donors

20 African Americans and Organ Donation AA are the largest minority group in need of an organ transplant AA comprise 13% of population AA comprise 33% of the kidney waiting list AA comprise 20% of the heart waiting list 17% of all organ doors in 2010 were AA

21 Hispanics and Organ Donation Hispanics comprise 16% of the population Hispanics comprise 18% of kidney waiting list Hispanics comprise 17% of liver waiting list 13% of all deceased donors were Hispanic

22 Kidney Waiting List First come, first served Genetic matching Local organs stay locally Priority given to sensitized patients Priority to children

23 Source: HRSA U.S. Organ Procurement and Transplantation Network (OPTN). Based on OPTN data as of February 24, U.S. Transplant Waiting List Candidates by Race/Ethnicity Organ # of Black candidates Black % of all candidates # of White candidates White % of all candidates All Organs 35, % 55,204 45% Kidney 32, % 37, % Liver 1, % 11, % Heart % 2, % Lung % 1, %

24 Transplants Performed in the U.S. by Recipient Ethnicity 2011 % of total 2011 transplants Black 5, % White 15, % Total Transplants 26, %

25 U.S. Organ Donors Recovered, 2011 Donor Type # of Black donors Black % of all donors # of White donors White % of all donors Living % 3, % Deceased 1, % 4, % Total 1, % 8, %

26 Distribution of Patients Awaiting Kidney Transplants

27 % dialysis pts who are waitlisted

28 Kidney Transplant Candidates Increasing incidence of medical comorbidities 17% increase in the incidence of diabetes 30% increase in the incidence of hypertensive kidney disease Marked increase in the length of time on the kidney list. Varies markedly across the country Increased dialysis time results reduced post transplant survival and increased cost

29 Waitlist Problems From , Almost 2x in patients >65 yrs Patients <35 yrs from 18% to 12% Patients yrs from 35% to 29% Estimated that 50% of patients >60 yrs will die before receiving deceased donor kidney transplant Mortality 6%/yr for listed patients, 10% among diabetic patients

30 Waitlist Problems AA disproportionately higher represented on wait list (35%) compared to % of population (15%) AA less likely to be referred for transplant AA wait longer for transplant (2x Cauc) AA have higher rates of rejection and graft loss Recent study showed that even after adjustment for socioeconomic and clinical factors, AA have 59% lower rate of transplantation compared to Caucasians Patzer RE, et al. AJT 2012; 12:

31 From: Rates of Solid-Organ Wait-listing, Transplantation, and Survival Among Residents of Rural and Urban Areas JAMA. 2008;299(2): doi: /jama

32 Disparities in Providing Transplant Information Study looking at patients newly diagnosed with ESRD between % not informed about transplant Older Obese Medicaid Pts at for-profit dialysis centers Many providers still believe patients need to be on dialysis for a period before transplant considered! Kucirka LM, et al. AJT 2012; 12:

33 How About the Costs of Transplant?

34 Kidney Recipient Economics Incremental Cost of Kidney Transplant Dialysis >5 years Hypertension African American BMI > 30 Transplant 1 Year Age > 60 Diabetes Bucahanan et al. AJT 2008

35 Long Term Costs of Transplant Regression Model for 3 yr. increased Medicare payments Variable Regression Coefficient Age (per year) 33 Female Gender 1311 African American 10,377 Hispanic 4829 Other race -6,066 BMI (per kg/m 2 ) 521 Type II DM 2373 Dialysis duration (per month) 127 Machnicki G, et al. Saudi J Kid Dis 2011; 22(1): 24-39

36 Transplant rates among patients wait-listed for a kidney transplant, by age

37 Median years to kidney transplant for wait-listed adult patients

38 Kidney transplant waiting list activity among adult patients

39 Median years to kidney transplant (deceased donor) for adult patients transplanted in 2009, by DSA

40 Kidney donations from deceased donors per million population

41 Kidney donations from living donors

42 Adult kidney transplants

43 Making Use of Scarce Utilities SCD Standard Criteria Donors ECD Extended Criteria Donors DCD Donation after Cardiac Death

44 Trends in Organ Donation

45 Reliance on more marginal donors

46 Centers transplanting ECD & DCD deceased donor kidneys,

47 Delayed graft function among adult kidney transplant recipients

48 All KTx saves $ for society $350,000 $338k $320k $295k $285k $300,000 $250,000 $200,000 $150,000 $100,000 Dialysis ECD DCD Standard $50,000 $0 Cost Discounted lifetime cost of Dialysis vs. ECD,DCD, SCD TXP

49 Outcomes among adult kidney transplant recipients: deceased donor

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51 Race as Risk Factor for Transplant Center Data Donor age: 0-17 yr (ref yr) Coefficient Odds Ratio Donor age: yr Donor age: yr Donor age: 65 yr Recipient race: Black (ref white) Recipient race: Hispanic, Latino Recipient race: Asian Recipient race: other/missing Odds Ratio > 1, failure/death more likely. Odds Ratio < 1, failure/death less likely.

52 Move to Change Allocation to More Utilitarian Too many people dying with functioning graft Move to add survival benefit to allocation algorithm Plan in consideration to give best kidneys to those with most chance of survival Penalty for old, diabetic patients

53 Sickest Patient First! Liver Allocation Scoring system called MELD used Organs allocated by blood type, not genetic match

54 Shooting Ourselves in the Foot? Facts Hepatitis C most common indication for liver transplant Much more frequent in minorities and poorer socioeconomic classes High prevelance among dialysis patients Disease not easily cured by transplant 100% recurrence! Worst survival outcomes

55 Table 8. Univariate Factors that Have an Effect on Whether a Patient Has an Expensive ICU Stay Factor Hazard Ratio 95% CI P Value Male (versus female) Age Time on list Retransplant Budd-Chiari syndrome ALD Child-Pugh score MELD score MELD (versus <11) MELD (versus <11) MELD >24 (versus <11) Foxton, M. R., et al Liver Transpl, 16:

56 Median MELD score for adult deceased donor liver transplants, by DSA, 2009

57 Distribution of adult patients waiting for a liver transplant

58 Median months to liver transplant for adult patients transplanted in 2009, by DSA

59 Median months to liver transplant for wait-listed adult patients

60 Deceased donor liver donation rates (per million population, age <70), by state: 2004

61 Deceased donor liver donation rates (per million population, age <70), by state: 2009

62 Adult liver transplants

63 Graft failure among adult liver transplant recipients: deceased donor

64 Health Care Reform and Transplant Health insurance reform Expanded access Premium and out of pocket caps Medicaid changes More transplant patients with Medicaid coverage Medicare changes Proposed overall cuts in reimbursement Independent Medicare review board

65 Growth in the Medicaid Program Beneficial to Transplant Improved access to transplant Coverage for uninsured patients in the post transplant period Reduced organ loss to medication non-adherence Adverse for transplant Expansion in patients with inadequate coverage Medicaid payments often do not cover organ acquisition costs Potential shift in patients with private insurance to lower cost or free public care.

66 Changes in Medicare Dramatic reduction in overall spending in Medicare program Directed by an independent advisory board Closes the Medicare prescription coverage donut hole Reliance on quality metrics Reduce/eliminate payments for re-admissions Limit payments for marginally effective services Increased fraud and abuse surveillance and enforcement

67 Changes in Medicare Beneficial to Transplant Better drug coverage through reduction in the donut hole Anticipated stabilization of the sustainable growth rate Adverse for transplant Reimbursement reductions for professional services Penalties for complications Will tx centers not transplant higher risk patients? Will research suffer as centers risk averse to trying experimental drugs and procedures?

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69 Success is how you look at it Multiculturalism represents real and significant challenges to organ transplant - System as exists is more beneficial than utilitarian Donors for organs have worsened Racial bias in allocation? Implications for insurance coverage?

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