Health-related and psychosocial concerns about transplantation among patients initiating dialysis

Abstract

Background and objectives: Disparities in kidney transplantation remain; one mechanism for disparities in access to transplantation (ATT) may be patient-perceived concerns about pursuing transplantation. This study sought to characterize prevalence of patient-perceived concerns, explore interrelationships between concerns, determine patient characteristics associated with concerns, and assess the effect of concerns on ATT.

Design, setting, participants, & measurements: Prevalences of 12 patient-perceived concerns about pursuing transplantation were determined among 348 adults who recently initiated dialysis, recruited from 26 free-standing dialysis centers around Baltimore, Maryland (January 2009-March 2012). Using variable reduction techniques, concerns were clustered into two categories (health-related and psychosocial) and quantified with scale scores. Associations between patient characteristics and concerns were estimated using modified Poisson regression. Associations between concerns and ATT were estimated using Cox models.

Results: The most frequently cited patient-perceived concerns were that participants felt they were doing fine on dialysis (68.4%) and felt uncomfortable asking someone to donate a kidney (29.9%). Older age was independently associated with having high health-related (adjusted relative risk, 1.35 [95% confidence interval, 1.20 to 1.51], for every 5 years older for those ≥ 60 years) or psychosocial (1.15 [1.00 to 1.31], for every 5 years older for those aged ≥ 60 years) concerns, as was being a woman (1.72 [1.21 to 2.43] and 1.55 [1.09 to 2.20]), having less education (1.59 [1.08 to 2.35] and 1.77 [1.17 to 2.68], comparing postsecondary education to grade school or less), and having more comorbidities (1.18 [1.08 to 1.30] and 1.18 [1.07 to 1.29], per one comorbidity increase). Having never seen a nephrologist before dialysis initiation was associated with high psychosocial concerns (1.48 [1.01 to 2.18]). Those with high health-related (0.37 [0.16 to 0.87]) or psychosocial (0.47 [0.23 to 0.95]) concerns were less likely to achieve ATT (median follow-up time 2.2 years; interquartile range, 1.6-3.2).

Conclusions: Patient-perceived concerns about pursuing kidney transplantation are highly prevalent, particularly among older adults and women. Reducing these concerns may help decrease disparities in ATT.

Keywords: ESRD; barriers; dialysis; epidemiology; outcomes; transplantation.

Figure 1.

Relationship between measured individual concerns and underlying latent constructs. This figure depicts the concept behind using exploratory factor analysis in identifying underlying latent constructs (i.e., factors) that give rise to the measured individual concerns (measured variables). Using this methodologic approach, we identified two underlying latent constructs (health-related and psychosocial concerns), which each comprised five of the measured concerns. Two of the measured individual concerns (“I’m doing fine on dialysis” and “No one has discussed kidney transplantation with me”) were not representative of an underlying latent construct.

Figure 2.

Access to transplantation by patient-perceived concerns about pursuing KT. (A) “I’m doing fine on dialysis” (as a reason not to pursue KT). (B) “No one has discussed KT with me” (as a reason not to pursue KT). (C) Levels of health-related concerns. (D) Levels of psychosocial concerns. Concerns were categorized empirically into health-related or psychosocial categories. “I’m doing fine on dialysis” and “No one has discussed KT with me” did not fall into either health-related or psychosocial concerns categories. High and low levels of health-related and psychosocial concerns are based on comparing the highest quartile to the lower three quartiles of scale scores. See the Materials and Methods and the Supplemental Appendix for a description of the exploratory factor analysis used to categorize concerns and for creation of scale scores. See Table 2 for individual concerns. KT, kidney transplantation.