Introduction

There are many potential factors which are associated with patient outcomes beyond traditional clinical and donor characteristics.

Methods

We merged national SRTR data with data aggregated from multiple national databases which characterize behavioral and environmental factors, availability of healthcare providers, and comorbid conditions for every county in the United States. We evaluated the association of individual community risk factors and an aggregate community risk score (scaled from 0[lowest risk] to 40[highest risk]) on six primary outcomes for solitary kidney transplant candidates in the US from 2004-11(n=209,198): (1) wait list mortality (2) time to transplantation and (3) likelihood of a living donor transplant (4) time to wait list removal for health deterioration (5) likelihood of preemptive listing for transplantation and (6) likelihood of initial listing as inactive.

Results

After adjustment for traditional candidate factors, patients residing in the top quartile (highest level) of community risk, were associated with increased mortality (AHR=1.21,1.16-1.27), decreased likelihood of living donor transplantation (AHR=0.90, 0.85-0.94), increased risk of wait list removal (AHR=1.36,1.22-1.51), decreased likelihood of preemptive listing (AOR=0.85,0.81-0.88) and increased likelihood of initial listing as inactive (AOR=1.49,1.43-1.55). There was no association with time to deceased donor transplantation. The average community risk score varied widely by region and individual transplant center (min=5,q1=14,median=21,q3=26,max=37).

Conclusions

Community risk factors are powerful factors explaining both processes of care and outcomes for transplant candidates. These results are critical towards understanding effective interventions for patients as well as appropriately measuring the quality of care of centers that care for patients from higher risk communities.

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