Inequity in access to transplantation in the UK

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

Assessing Consensus Between UK Renal Clinicians on Listing for Kidney Transplantation: A Modified Delphi Study.

BACKGROUND: It is well recognized that there is significant variation between centers in access to kidney transplantation. In the absence of high-grade evidence, it is unclear whether variation is due to patient case mix, other center factors, or individual clinician decisions. This study sought consensus between UK clinicians on factors that should influence access to kidney transplantation. METHODS: As part of the Access to Transplantation and Transplant Outcome Measures project, consultant nephrologists and transplant surgeons in 71 centers were invited to participate in a Delphi study involving 2 rounds. During rounds 1 and 2, participants rated their agreement to 29 statements covering 8 topics regarding kidney transplantation. A stakeholder meeting was used to discuss statements of interest after the 2 rounds. RESULTS: In total, 122 nephrologists and 16 transplant surgeons from 45 units participated in rounds 1 and 2. After 2 rounds, 12 of 29 statements reached consensus. Fifty people participated in the stakeholder meeting. After the stakeholder meeting, a further 4 statements reached agreement. Of the 8 topics covered, consensus was reached in 6: use of a transplant protocol, patient age, body mass index, patient compliance with treatment, cardiac workup, and use of multidisciplinary meetings. Consensus was not reached on screening for malignancy and use of peripheral Doppler studies. CONCLUSIONS: The Delphi process identified factors upon which clinicians agreed and areas where consensus could not be achieved. The findings should inform national guidelines to support decision making in the absence of high quality evidence and to guide areas that warrant future research

Exploring inequity in access to renal transplantation

Transplantation is the most cost effective treatment for end stage renal disease (ESRD), but demand outstrips supply. In the UK, retrospective analyses of Registry data show there is variation in access to transplantation between renal centres, and that despite ethnic minority populations and those from lower socioeconomic groups having a higher incidence of ESRD, they have reduced access to transplantation. As part of the NIHR funded ATTOM (Access to Transplantation and Transplant Outcome Measures) study, a mixed methods approach explored the impact of both the compositional properties of a centre and modifiable centre factors relating to organisation and processes of care, on access to transplant listing. The inter-personal relationships between living kidney donors and their recipients were also examined.Thematic analysis of 45 semi-structured qualitative interviews with key stakeholders conducted across 9 renal centres in the UK informed the development of an online survey, which was, distributed to the Clinical Directors of all 71 UK renal centres. Major themes identified were pathways of care relating to transplant recipient assessment and chronic kidney disease management as well as cardiac assessment and decision-making. The subsequent national survey achieved a 100% response rate and demonstrated significant variation in the assessment criteria of patients, delivery of care, role of multi-disciplinary teams and level of transplant surgical involvement prior to listing. A prospective cohort of incident renal replacement therapy (RRT) patients in ATTOM with 18 month follow up were subsequently analysed to assess listing for transplantation. A multi-level hierarchical logistic regression model was used to assess factors associated with listing. The majority of observed inter-centre variation was accounted for by patient factors including independently age, ethnicity, socioeconomic status and several co-morbidities. Centre factors included the use of a written protocol to wait-list, whether the centre was a transplanting centre, and the universal discussion of transplantation with all patients. The study on living donor-recipient relationships demonstrated that living-kidney donation is subject to significant unexplained relationship differences amongst ethnic-minorities. Spousal donation is significantly lower in the Black population and gender disparity greatest in the Asian spousal population.Further research is need to understand these observed differences to tackle inequity in access to transplantation for socially deprived patients and ethnic minorities as well as to to increase donation rates in ethnic minorities. There is also need for consensus on recipient work up and between centre harmonisation, as well as research to examine cardiovascular screening utility in potential transplant recipients

Unconsciously interactive Films in a cinema environment—a demonstrative case study

© 2018 Informa UK Limited, trading as Taylor & Francis Group ‘Many worlds’ is a short narrative live-action film written and directed so as to provide multiple linear routes through the plot to one of four endings, and designed for showing in a cinema environment. At two points during the film, decisions are made based on audience bio-signals as to which plot route to take. The use of bio-signals is to allow the audience to remain immersed in the film, rather than explicitly selecting plot direction. Four audience members have a bio-signal measured sensor for each person: ECG (heart rate), EMG (muscle tension), EEG (‘brain waves’) and Galvanic Skin Response (perspiration). The four are interpreted as a single average of emotional arousal. ‘Many worlds’ was the first live-action linear plotted film to be screened in a cinema to the general public utilizing multiple biosensor types. The film has been shown publically a number of times, and lessons learned from the technical and cinematic production are detailed in this paper

Managing uncertainty in multidisciplinary renal team meetings: decision-making processes and complex challenges in kidney transplant listing

Multidisciplinary team (MDT) meetings are common to many fields of medicine and widely established internationally. They are intended to ensure higher-quality decision-making and improved patient outcomes. For patients with end-stage kidney disease (ESKD), decisions on whether to place marginally suitable candidates on the kidney transplantation waiting list can be challenging and as such they are supported by MDT meetings. Uncertainty in terms of the best course of action can be linked with a dearth of knowledge or evidence on specific medical conditions and likely implications for successful transplantation, but also on unforeseen outcomes influenced by patient behaviours. In this project, we observed how MDT meetings work in practice in kidney transplant listing, unpacking issues of risk and uncertainty in transplant decision-making processes. Our findings indicate that a central value of MDT meetings is managing medical uncertainty and psychosocial risks, and distributing responsibility for complex transplant listing decisions to ensure equity of access to transplantation as well as an efficient use of scarce kidneys. This sheds light on strategies enacted to mitigate these risks and uncertainties, and the role played by different types of knowledge (experiential versus scientifically evidence-based) in the overall decision-making process.</p

Managing uncertainty in multidisciplinary renal team meetings : decision-making processes and complex challenges in kidney transplant listing

Multidisciplinary team (MDT) meetings are common to many fields of medicine and widely established internationally. They are intended to ensure higher-quality decision-making and improved patient outcomes. For patients with end-stage kidney disease (ESKD), decisions on whether to place marginally suitable candidates on the kidney transplantation waiting list can be challenging and as such they are supported by MDT meetings. Uncertainty in terms of the best course of action can be linked with a dearth of knowledge or evidence on specific medical conditions and likely implications for successful transplantation, but also on unforeseen outcomes influenced by patient behaviours. In this project, we observed how MDT meetings work in practice in kidney transplant listing, unpacking issues of risk and uncertainty in transplant decision-making processes. Our findings indicate that a central value of MDT meetings is managing medical uncertainty and psychosocial risks, and distributing responsibility for complex transplant listing decisions to ensure equity of access to transplantation as well as an efficient use of scarce kidneys. This sheds light on strategies enacted to mitigate these risks and uncertainties, and the role played by different types of knowledge (experiential versus scientifically evidence-based) in the overall decision-making process