Toward Reducing Inequity in Transplantation of the Socioeconomic Disadvantaged: A Glimmer of Hope?

There is abundant evidence that social and economic deprivation (SED) adversely impacts health: those who are socially deprived generally have reduced access to health care, delayed treatment, a greater burden of disease and worse health outcomes including higher mortality, and reduced life expectancy.1,2 Reasons are multifactorial and include financial hardship, digital illiteracy, distrust in the healthcare system, a greater burden of mental and psychological illness, less healthy lifestyles (such as greater risk of smoking and obesity), and logistical issues. The issues are complex, solutions are challenging and have to be addressed at many different levels of society and by many different players3 Organ donation and transplantation follow this sad pattern4,5: those living in areas of greater deprivation have higher rates of kidney failure, reduced access to home therapies, transplant listing, and early transplantation; furthermore, they are younger and more likely to be from ethnic minority groups. Outcomes after transplantation are worse. Those who are more deprived are slightly less likely to agree to donation.6 Living donation is also generally less common amongst the socioeconomically deprived.7 Of those who are listed, however, the picture is less clear: national organ allocation policies seek to balance equity with justice, fairness, benefit, and utility, and none (as far as the author is aware) include any measure of social deprivation, directly or indirectly. Inclusion of HLA matching in organ allocation may indirectly disadvantage some groups because there are clear differences in donation rates (and refusal to donate)6 among ethnic groups, and this may impact of waiting times for those organs (such as kidney) where such matching is relevant to outcomes. Furthermore, living donation is less common in some ethnic groups, thus affecting both waitlist times and mortality. However, because there is a variable association between SED and ethnicity, it may be difficult to determine the individual effects of these 2 variables. Against this depressing background, the recent retrospective study by Corr et al7 offered some valuable insights: they compared access to and outcomes of kidney transplantation in England and Northern Ireland (NI). They found in England, SED was associated with reduced transplant access, lower rates of preemptive and living donor transplantation, and poorer graft and patient survival. These disparities persisted across ethnic groups. In contrast, NI showed no significant SED-related differences in transplant access despite a more deprived population overall. However, caution must be used when comparing outcomes in NI and England, and the findings must be considered within the limitations of the data. Although the 2 nations share some commonalities, such as a nationalized healthcare system, free to the user at point of delivery, and a UK-wide organ allocation system for deceased donor organs, there are significant differences: the population of England is about 56.5 million and NI 1.95 million; England is served by 19 adult renal transplant units with no defined boundaries for the population they serve and NI by 1 unit. Health deprivation is particularly pronounced for NI—nearly 28% of areas in NI rank within the most deprived 10% by poor health across the United Kingdom. However, within the rest of the United Kingdom, there is marked variation (23% in Scotland, 16% in the North East of England and, at the other extreme, just 1.5% of areas in London, and 2.65% in the east of England).8 Although NI has become more ethnically diverse over the past 2 decades, just 3.4% of the population are from an ethnic minority group compared with 18.3% in England and Wales, and a greater proportion of the NI population have English as their first language.9 With these caveats in mind, the findings from NI do offer some grounds for hope that disparities caused by socioeconomic deprivation can be mitigated, at least in part, by the local healthcare community. The authors suggest their success is because of a number of factors: these include the service configuration and coherence with a single integrated center enabling more consistent referral, assessment, activation for transplantation and follow-up of recipients, sustained public engagement and close collaboration across renal and transplant services in NI, a strong sense of community and leadership by dedicated healthcare professionals in a center that boasts short risk-adjusted waiting times for deceased kidneys, low rates of decline of allocated organs, and high rates of living donation. It is not clear whether any of these factors were introduced with the aim of reducing disparities in equity. Of course, as the authors acknowledge, these broad conclusions need validation and more detailed analysis. For example, it would be of interest to conduct a comparable analysis across other organs in NI and between NI and other regions of the United Kingdom, especially those with a degree of SED similar to that seen in NI. SED is graded and not binary with many diverse factors affecting the measurement of deprivation so it would be helpful to investigate how these factors might be improved by targeted interventions. The interaction between ethnicity and deprivation is complex, and the proportion of patients from NI was too small to allow for closer analysis. There are many different ethnic groups, and there is significant variation between ethnic groups with respect to many factors that affect the journey from disease to transplant survival (including burden and cause of renal disease, access to medical services, and willingness to donate) as well as SED, so more work is needed to understand the interaction. Nonetheless, these observations do provide the basis for an approach that will go some way to remove some inequity for some of the population but remain no substitute for a broader approach to reduce health inequality. Reducing inequity in healthcare and improving outcomes for the disadvantaged is challenging, and there is no simple solution, but by tackling some of the social and financial causes of health, local NHS services can complement the work of national bodies to improve healthcare10; the NI experience suggest that national policies alone are inadequate and that local collaborations and structures can be successful even in the face of a general increase in inequity.