Excluding patients from transplant due to social support: Results from a national survey of transplant providers

Abstract

Social support is used to determine transplant eligibility despite lack of an evidence base and vague regulatory guidance. It is unknown how many patients are disqualified from transplantation due to inadequate support, and whether providers feel confident using these subjective criteria to determine eligibility. Transplant providers (n = 551) from 202 centers estimated that, on average, 9.6% (standard deviation = 9.4) of patients evaluated in the prior year were excluded due to inadequate support. This varied significantly by United Network for Organ Sharing region (7.6%-12.2%), and by center (21.7% among top quartile). Significantly more providers used social support in listing decisions than believed it ought to be used (86.3% vs 67.6%). Nearly 25% believed that using social support in listing determinations was unfair or were unsure; 67.3% felt it disproportionately impacted patients of low socioeconomic status. Overall, 42.4% were only somewhat or not at all confident using social support to determine transplant suitability. Compared to surgical/medical transplant providers, psychosocial providers had 2.13 greater odds of supporting the criteria (P = .03). Furthermore, 69.2% supported revised guidelines for use of social support in listing decisions. Social support criteria should be reconsidered in light of the limited evidence, potential for disparities, practice variation, low provider confidence, and desire for revised guidelines.

Keywords: clinical decision-making; ethics; ethics and public policy; guidelines; health services and outcomes research; kidney transplantation/nephrology; organ transplantation in general; patient characteristics; recipient selection; social sciences.

FIGURE 1

Attitudes regarding use of social support criteria in waitlisting determinations from a national sample of transplant providers (n = 551). Social support is abbreviated as “SS.” Response categories for “How confident are you in using SS to make determinations about transplant eligibility?” are extremely/very confident, somewhat confident, not at all confident. SES, socioeconomic status