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Original ArticlesTransplantation
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Inequity in Access to Transplantation in the United Kingdom

Rishi Pruthi, Matthew L. Robb, Gabriel C. Oniscu, Charles Tomson, Andrew Bradley, John L. Forsythe, Wendy Metcalfe, Clare Bradley, Christopher Dudley, Rachel J. Johnson, Christopher Watson, Heather Draper, Damian Fogarty, Rommel Ravanan, Paul J. Roderick and on behalf of the ATTOM Investigators
CJASN June 2020, 15 (6) 830-842; DOI: https://doi.org/10.2215/CJN.11460919
Rishi Pruthi
1Transplant, Renal and Urology Directorate, Guy’s and St. Thomas’ National Health Service Foundation Trust, London, United Kingdom
2Academic Unit of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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Matthew L. Robb
3Statistics and Clinical Studies, National Health Service Blood and Transplant, Bristol, United Kingdom
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Gabriel C. Oniscu
4Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Charles Tomson
5Renal Unit, Freeman Hospital, Newcastle, United Kingdom
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Andrew Bradley
6Department of Surgery, University of Cambridge and the National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom
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John L. Forsythe
4Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Wendy Metcalfe
4Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Clare Bradley
7Health Psychology Research Unit, Royal Holloway, University of London, Egham, United Kingdom
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Christopher Dudley
8Richard Bright Renal Unit, Southmead Hospital, Bristol, United Kingdom
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Rachel J. Johnson
3Statistics and Clinical Studies, National Health Service Blood and Transplant, Bristol, United Kingdom
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Christopher Watson
6Department of Surgery, University of Cambridge and the National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom
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Heather Draper
9Department of Social Science and Systems in Health, University of Warwick, Coventry, United Kingdom
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Damian Fogarty
10Nephrology Unit, Belfast Health and Social Care Trust, Belfast, Northern Ireland, United Kingdom
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Rommel Ravanan
8Richard Bright Renal Unit, Southmead Hospital, Bristol, United Kingdom
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Paul J. Roderick
2Academic Unit of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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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.

  • clinical epidemiology
  • Epidemiology and outcomes
  • ethnicity
  • kidney transplantation
  • inequity
  • socio-economic deprivation
  • transplant waiting list
  • renal dialysis
  • Ethnic Groups
  • Minority Groups
  • Universal Health Care
  • Cohort Studies
  • Body Mass Index
  • Prospective Studies
  • Social Class
  • Renal Replacement Therapy
  • African Americans
  • Diagnosis-Related Groups
  • Outcome Assessment
  • Health Care
  • Received September 23, 2019.
  • Accepted April 24, 2020.
  • Copyright © 2020 by the American Society of Nephrology
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Clinical Journal of the American Society of Nephrology: 15 (6)
Clinical Journal of the American Society of Nephrology
Vol. 15, Issue 6
June 08, 2020
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Inequity in Access to Transplantation in the United Kingdom
Rishi Pruthi, Matthew L. Robb, Gabriel C. Oniscu, Charles Tomson, Andrew Bradley, John L. Forsythe, Wendy Metcalfe, Clare Bradley, Christopher Dudley, Rachel J. Johnson, Christopher Watson, Heather Draper, Damian Fogarty, Rommel Ravanan, Paul J. Roderick, on behalf of the ATTOM Investigators
CJASN Jun 2020, 15 (6) 830-842; DOI: 10.2215/CJN.11460919

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Inequity in Access to Transplantation in the United Kingdom
Rishi Pruthi, Matthew L. Robb, Gabriel C. Oniscu, Charles Tomson, Andrew Bradley, John L. Forsythe, Wendy Metcalfe, Clare Bradley, Christopher Dudley, Rachel J. Johnson, Christopher Watson, Heather Draper, Damian Fogarty, Rommel Ravanan, Paul J. Roderick, on behalf of the ATTOM Investigators
CJASN Jun 2020, 15 (6) 830-842; DOI: 10.2215/CJN.11460919
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Keywords

  • clinical epidemiology
  • epidemiology and outcomes
  • ethnicity
  • kidney transplantation
  • inequity
  • socio-economic deprivation
  • transplant waiting list
  • renal dialysis
  • Ethnic Groups
  • Minority Groups
  • Universal Health Care
  • cohort studies
  • Body Mass Index
  • Prospective Studies
  • Social Class
  • renal replacement therapy
  • African Americans
  • Diagnosis-Related Groups
  • Outcome Assessment
  • Health Care

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