Community health indicators may be associated with post-transplant mortality for kidney recipients, according to a study published Online First by Archives of Surgery, one of the JAMA/Archives journals.
Researchers used data from several national registries and considered community health factors, including poor mental and physical health, proportion of low birth weights and smokers, obesity prevalence, inactivity rate and years of potential life lost. Cumulative community health-risk scores were generated for the counties where recipients lived.
The study by Jesse D. Schold, Ph.D., of the Cleveland Clinic, and colleagues included 100,164 living and deceased donor adult (age ≥ 18 years) kidney transplant recipients who received their new organs between Jan. 1, 2004 and Dec. 31, 2010.
Their results suggest that patients from the highest-risk counties were associated with significant unadjusted hazard for overall graft loss and post-transplant mortality. The association of the highest-risk counties with mortality was stronger among counties with larger populations. Kidney recipients in higher-risk counties were more likely to be African American, to be younger, to have attained less education and have public health insurance.
“In summary, the principal findings of our study are that community health indicators are significantly associated with transplant recipient outcomes. These indicators are independent of traditional clinical risk factors and are highly variable across the country,” the researchers comment.
They note there are a number of potential explanations for the association of community health indicators and transplant outcomes.
“The behavioral and socioeconomic conditions of the communities in which patients reside may also reflect risks that patients are exposed to in their environment before and after undergoing transplant but that are not consistently documented,” they comment. “However, it is also important for interpretation of our study findings that ascribing broad area risks to each individual within that area is an ecological fallacy. Thus, although there appear to be significant risks associated with certain communities, it is inappropriate to directly assign risks to individuals within that community.”
The researchers suggest an important consideration for their findings is the association of community health indicators and performance indicators.
“For many other health care contexts, report cards and quality performance assessments have increasing ramifications on hospital reimbursement,” they write.
In an invited commentary, Douglas P. Slakey, M.D., of Tulane University , New Orleans , writes: “Schold et al demonstrate that kidney transplant outcomes are affected by more than what can be measured on the individual level. Some have suspected a relationship between community health indicators and outcomes, but credible data to support this belief have, until now, been lacking.”
“The effects of the conclusions are sobering and certainly extend beyond kidney transplantation. Given the increasing emphasis on outcome measures and pay-for-performance, the consequences of the authors’ findings cannot be ignored. Whether it is done consciously or unconsciously, providers of care are going to impose barriers to access to care for patients from high-risk environments.”
(Arch Surg. doi:10.1001/archsurg.2011.2220; doi:10.1001/archsurg.2012.1