The Effect of the Statewide Sharing Variance on Geographic Disparity in Kidney Transplantation in the United States
The Effect of the Statewide Sharing Variance on Geographic Disparity in Kidney Transplantation in the United States
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DOI：
10.2215/cjn.05350513
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发表时间：
2014-08-01
影响因子：
9.8
通讯作者：
Ladner, Daniela P.
中科院分区：
文献类型：
--
作者：
Davis, Ashley E.;Mehrotra, Sanjay;Ladner, Daniela P.
背景和目标 全州共享与国家肾脏分配政策的差异是，首先在州内分配未在采购捐赠服务区 (DSA) 内使用的肾脏，然后再在区域和全国范围内提供肾脏。田纳西州和佛罗里达州实施了这一差异。 58 个 DSA 之间存在已知的地理差异，这直接违反了美国卫生与公共服务部制定的最终规则。本研究考察了全州共享对田纳西州和佛罗里达州 DSA 之间地理分配差异的影响，并将其与拥有多个 DSA 的所有州（加利福尼亚州、纽约州、北卡罗来纳州、俄亥俄州、宾夕法尼亚州、德克萨斯州和威斯康星州）的州内 DSA 之间的地理分配差异进行比较。 设计、设置、参与者和测量 使用器官采购和移植网络数据对 1987 年至 2009 年进行了回顾性分析。应用了以前使用的五个地理分配差异指标：死者供肾移植率、移植等待时间、移植时累积透析时间、5年移植物存活时间和冷缺血时间。 结果 1987年各州DSA中死者供肾受者之间的移植率、等待时间、透析时间和移植物存活率差异很大。1992年实施全州共享后，差距指标下降了田纳西州分别为 41%、36%、31% 和 9%，佛罗里达州分别为 28%、62%、34% 和 19%，田纳西州和佛罗里达州的地理分配差异几乎完全消失。全州范围内的肾脏分配导致田纳西州和佛罗里达州的冷缺血时间分别减少了 7.5 小时和 5 小时。所有其他州的 DSA 之间的地理差异都在较小程度上恶化或改善。 结论 随着正在讨论对肾脏分配系统进行彻底改变以缓解地理差异（未经测试的改变可能会带来意想不到的后果），应该进一步研究和考虑更有限的改变，例如全州共享。
Background and objectives The Statewide Sharing variance to the national kidney allocation policy allocates kidneys not used within the procuring donor service area (DSA), first within the state, before the kidneys are offered regionally and nationally. Tennessee and Florida implemented this variance. Known geographic differences exist between the 58 DSAs, in direct violation of the Final Rule stipulated by the US Department of Health and Human Services. This study examined the effect of Statewide Sharing on geographic allocation disparity over time between DSAs within Tennessee and Florida and compared them with geographic disparity between the DSAs within a state for all states with more than one DSA (California, New York, North Carolina, Ohio, Pennsylvania, Texas, and Wisconsin).Design, setting, participants, & measurements A retrospective analysis from 1987 to 2009 was conducted using Organ Procurement and Transplant Network data. Five previously used indicators for geographic allocation disparity were applied: deceased-donor kidney transplant rates, waiting time to transplantation, cumulative dialysis time at transplantation, 5-year graft survival, and cold ischemic time.Results Transplant rates, waiting time, dialysis time, and graft survival varied greatly between deceased-donor kidney recipients in DSAs in all states in 1987. After implementation of Statewide Sharing in 1992, disparity indicators decreased by 41%, 36%, 31%, and 9%, respectively, in Tennessee and by 28%, 62%, 34%, and 19%, respectively in Florida, such that the geographic allocation disparity in Tennessee and Florida almost completely disappeared. Statewide kidney allocations incurred 7.5 and 5 fewer hours of cold ischemic time in Tennessee and Florida, respectively. Geographic disparity between DSAs in all the other states worsened or improved to a lesser degree.Conclusions As sweeping changes to the kidney allocation system are being discussed to alleviate geographic disparity-changes that are untested run the risk of unintended consequences-more limited changes, such as Statewide Sharing, should be further studied and considered.