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Saturday, February 16, 2008

Race Matters for Patients awaiting Lung Transplants

A recent study published in the American Journal of Respiratory and Critical Care Medicine finds that compared to whites, blacks with chronic obstructive pulmonary disease, or COPD, were less likely to receive a lung transplant. Blacks were also more likely than whites to die or be removed from the transplant list.

Columbia University researcher David Lederer and colleagues analyzed 280 non-Hispanic black adults and 5,272 non-Hispanic white adults who were diagnosed with COPD or emphysema. All members of the sample were awaiting lung transplants on the United Network for Organ Sharing (UNOS) list between 1995 and 2004. The researchers tracked patients to the end of the study period until they died, received a transplant, were removed from the list, or were still living and awaiting transplant. The results were examined with respect to age, sex, disease severity, community poverty level, and transplant center volume.

After controlling for age, lung function, cardiovascular risk factors, transplant center volume, type of health insurance, and approximate poverty level, Lederer and colleagues showed that "black patients with COPD were less likely to undergo lung transplantation after listing than white patients in the United States during the late 1990's and the early 2000's"

They note that this finding and other "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."

Blacks were also less likely to have private insurance and more likely to live in poorer neighborhoods. Greater cardiovascular risk factors, such as diabetes, pulmonary hypertension and lower six-minute walk distances were observed in blacks compared to whites. However, even these factors did not account for the differences between the two groups regarding lung transplantation.

"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.

The researchers also found that Hispanics had similar outcomes to non-Hispanic blacks. During the ten-year study period, only 280 black and 64 Hispanic patients with COPD were put on the lung transplant waiting list in the United States. Lederer adds that "based on what we know about COPD, we expected that twice as many black patients would have been put on the ling transplant waiting list. Our findings point to significant barriers to accessing lung transplantation for minorities."

The authors maintain that their 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." In addition, patients can protect themselves from these racial differences by preparing 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."

Since the study period, the organ allocation system has been replaced with one that prioritizes patients based on the survival benefit of the transplant. However, blacks will still be more likely to be removed from the transplant list or to die due to poor insurance and poverty compared to whites, warns Lederer.

The authors conclude by calling for research that identifies "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."

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