Inequity in Access to Transplantation in the United Kingdom

Abstract

Background and objectives: Despite the presence of a universal health care system, it is unclear if there is intercenter variation in access to kidney transplantation in the United Kingdom. This study aims to assess whether equity exists in access to kidney transplantation in the United Kingdom after adjustment for patient-specific factors and center practice patterns.

Design, setting, participants, & measurements: In this prospective, observational cohort study including all 71 United Kingdom kidney centers, incident RRT patients recruited between November 2011 and March 2013 as part of the Access to Transplantation and Transplant Outcome Measures study were analyzed to assess preemptive listing (n=2676) and listing within 2 years of starting dialysis (n=1970) by center.

Results: Seven hundred and six participants (26%) were listed preemptively, whereas 585 (30%) were listed within 2 years of commencing dialysis. The interquartile range across centers was 6%-33% for preemptive listing and 25%-40% for listing after starting dialysis. Patient factors, including increasing age, most comorbidities, body mass index >35 kg/m², and lower socioeconomic status, were associated with a lower likelihood of being listed and accounted for 89% and 97% of measured intercenter variation for preemptive listing and listing within 2 years of starting dialysis, respectively. Asian (odds ratio, 0.49; 95% confidence interval, 0.33 to 0.72) and Black (odds ratio, 0.43; 95% confidence interval, 0.26 to 0.71) participants were both associated with reduced access to preemptive listing; however Asian participants were associated with a higher likelihood of being listed after starting dialysis (odds ratio, 1.42; 95% confidence interval, 1.12 to 1.79). As for center factors, being registered at a transplanting center (odds ratio, 3.1; 95% confidence interval, 2.36 to 4.07) and a universal approach to discussing transplantation (odds ratio, 1.4; 95% confidence interval, 1.08 to 1.78) were associated with higher preemptive listing, whereas using a written protocol was associated negatively with listing within 2 years of starting dialysis (odds ratio, 0.7; 95% confidence interval, 0.58 to 0.9).

Conclusions: Patient case mix accounts for most of the intercenter variation seen in access to transplantation in the United Kingdom, with practice patterns also contributing some variation. Socioeconomic inequity exists despite having a universal health care system.

Keywords: African Americans; Body Mass Index; Cohort Studies; Diagnosis-Related Groups; Epidemiology and outcomes; Ethnic Groups; Health Care; Minority Groups; Outcome Assessment; Prospective Studies; Renal Replacement Therapy; Social Class; Universal Health Care; clinical epidemiology; ethnicity; inequity; kidney transplantation; renal dialysis; socio-economic deprivation; transplant waiting list.

Graphical abstract

Figure 1.

Flow diagram showing the study recruitment of participants (with inclusion and exclusion criteria) for (1) access to preemptive listing and (2) listing after starting dialysis. ATTOM, Access to Transplantation and Transplant Outcome Measures; NHS, National Health Service.

Figure 2.

Funnel plots showing variation in proportion of patients listed for preemptive kidney transplant by center, before, and after adjustment for patient and center factors. Centers with less than 10 observations are not shown. (A) Unadjusted center results. (B) Risk-adjusted for all patient and center factors using the mean of each adjustment variable across the cohort associated with preemptive listing as highlighted in Table 2. Number of patients denotes the number of participants from a given center who were analyzed (from the cohort of patients recruited at each center for the ATTOM study). CL, confidence limit.