Treatment Disparity Found For Blacks Awaiting Lung Transplant For Copd
Analysis of National Organ Sharing Stats Show Blacks Less Likely to Get a Transplant, More Likely to Die or Be Removed from the Waiting List than Whites NEW YORK – (Friday, Feb. 15, 2008) Blacks with chronic obstructive pulmonary disease (COPD) were less likely to receive a lung transplant and more likely to die or be removed from the transplant list than whites, according to a retrospective study of 78 U.S. transplant centers by Columbia University Medical Center researchers. COPD kills120,000 Americans a year and is the fourth leading cause of death in the U.S. “These disparities are consistent with those observed among patients awaiting kidney and liver transplantation and among patients with other advanced lung diseases such as pulmonary arterial hypertension and pulmonary fibrosis,” wrote lead researcher, David Lederer, M.D., M.S., assistant professor of medicine in the Division of Pulmonary, Allergy, and Critical Care Medicine at Columbia University College of Physicians and Surgeons. “This finding was independent of age, lung function, and transplant center volume.”
The findings were published in the second issue for February of the American Journal of Respiratory and Critical Care Medicine, published by the American Thoracic Society, www.thoracic.org.
Columbia researchers retrospectively assessed the entire cohort of 280 non-Hispanic black adults and 5,272 non-Hispanic white adults diagnosed with COPD or emphysema who were awaiting lung transplantation on the United Network for Organ Sharing (UNOS) list between Jan. 1, 1995 and Dec. 31, 2004. The investigators tracked the outcomes (death, transplantation, removal from the list, or still living) of the transplant-awaiting patients to the end of the study period and analyzed the results with respect to age, sex, disease severity, community poverty level and transplant center volume.
“We have shown that black patients with COPD were less likely to undergo lung transplantation after listing than white patients in the United States during the late 1990s and the early 2000s,” wrote Dr. Lederer. The one-year incidence of transplantation was 31 percent for blacks and 36 percent for whites. The five-year incidence was 62 percent for blacks and 68 percent for whites.
Strikingly, only 280 black and 64 Hispanic patients with COPD were put on the lung transplant waiting list in the United States during the 10-year study period. “Based on what we know about COPD, we expected that twice as many black patients would have been put on the lung transplant waiting list. Our findings point to significant barriers to accessing lung transplantation for minorities,” said Dr. Lederer. In the post-hoc analysis, the researchers also found that Hispanics had similar outcomes to non-Hispanic blacks.
The researchers did find that blacks were also less likely to have private insurance and more likely to live in poorer neighborhoods and have greater cardiovascular risk factors, such as diabetes, pulmonary hypertension and lower six-minute walk distances than whites. However, even these factors did not completely account for the findings.
“Differences in insurance, socioeconomic status, and cardiovascular risk factors explained some, but not all of the higher risk of death or removal from the waiting list,” said Dr. Lederer. “Our results suggest that race by itself was a determining factor for whether a patient received a transplant or not. Our hope is that this research will highlight the need for effective interventions to ensure equal outcomes for all patients with COPD.”
While the organ allocation system in place during the study period has been replaced with one that prioritizes patients based on the survival benefit of transplantation, Dr. Lederer cautions, the effects of poor insurance and poverty will likely still place blacks at increased risk for removal from the list or death.
For physicians, the implications of this research are clear. “These findings should alert primary care physicians and pulmonologists to consider referral of black patients with COPD for transplantation at the earliest signs of advanced disease.”
To protect themselves from these disparities, “patients with COPD should prepare themselves for transplantation by discussing all of their treatment options with their doctor. To be eligible for lung transplantation, patients must quit smoking, use medications and oxygen as prescribed, and participate in a pulmonary rehabilitation program to increase their strength and endurance,” said Dr. Lederer.
“The next step will be to identify the specific barriers that patients encounter, while trying to get on the waiting list for a lung transplant. Once we figure out the root of the problem, we can begin to improve access for all patients with COPD,” said Dr. Lederer.
Steven Kawut, M.D., M.S., Irving Assistant Professor of Clinical Medicine in the Division of Pulmonary, Allergy, and Critical Care Medicine at Columbia University College of Physicians and Surgeons (P&S), was the senior author of this study. Selim Arcasoy, M.D., associate professor of clinical medicine in the Division of Medicine at P & S, Joshua Sonett, M.D., professor of clinical surgery at P & S, Emma Benn, M.P.H., from the Department of Biostatistics at the Mailman School of Public Health (MSPH), R. Graham Barr, M.D., Dr. PH, Irving Assistant Professor of Medicine at P & S and assistant professor of epidemiology at MSPH, Jessie Wilt, M.D., assistant professor of clinical medicine, and Genevieve Reilly, FNCP from the Department of Surgery were co-authors.
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