Ongoing Research Needed to Improve Equity in Outcomes Following Lung Transplant

A recent cohort study of lung transplant donors and recipients revealed that socioeconomic position and region of residence did not account for the majority of differences in post-transplant outcomes seen among racial and ethnic groups.

These findings, which were recently published in the journal JAMA Network Open, highlight the complexities of racial and ethnic disparities, underscoring the need for continued efforts to address this issue and improve patient outcomes (2023;6(4):e238306).

“A recent National Academies of Sciences, Engineering, and Medicine study showed that transplant outcomes varied significantly based on a number of factors, including race, ethnicity and geographic location,” notes study author Carli J. Lehr, MD, PhD, Department of Pulmonary Medicine, Cleveland Clinic.

“We have noticed for some time that individuals who are Black have lower survival after transplant compared with white individuals,” she says. “And sometimes, it is assumed that disparities are primarily mediated by socioeconomic position, but we weren’t sure that explained these differences.”

Given the limited research on this issue in lung transplant, Dr. Lehr and colleagues initiated this study to answer the question of whether racial disparities after lung transplant are mediated by socioeconomic status and region.

Study methods and results

The study, which aimed to evaluate the role donor and recipient socioeconomic position and region plays in the racial and ethnic differences in post-transplant survival, included 19,504 lung transplant donors and recipients.

Donors and recipients had a median age of 33 years and 60 years, respectively. The race and ethnicity breakdown for donors was as follows: 3,117 (16.0%) were Hispanic individuals, 3,667 (18.8%) non-Hispanic Black individuals and 11,935 (61.2%) non-Hispanic white individuals. Among recipients participating in the study, 1,716 (8.8%) were Hispanic, 1,861 (9.5%) non-Hispanic Black and 15,375 (78.8%) non-Hispanic white.

Dr. Lehr and colleagues analyzed the association of donor and recipient race with area deprivation index (ADI) on post-transplant survival. Created by the Health Resources and Services Administration (HRSA), ADI is a measure of community-level socioeconomic disadvantage that includes domains of neighborhood economic hardship and inequality, financial strength and educational attainment, according to the study authors.

Data showed that ADI did not mediate the difference in post-transplant survival between non-Hispanic Black and non-Hispanic white transplant recipients. Additionally, ADI only mediated 4.1% of the survival difference between non-Hispanic Black and Hispanic recipients.

Dr. Lehr and colleagues also found that non-Hispanic white recipients had the highest proportion of individuals in the lowest ADI quintile — or most resourced — neighborhoods. Conversely, non-Hispanic Black and Hispanic recipients had the highest proportion of individuals in the highest ADI quintile, or least resourced, neighborhoods.

“Our data showed that not only were a lot of donors from more socially disadvantaged populations, but also it appears that a disproportionate amount of organ donations were going to individuals with lower levels of socioeconomic disadvantage,” says Dr. Lehr, while noting that this finding was concerning to the researchers.

The study authors also observed an increased risk of post-transplant death in non-Hispanic Black lung transplant recipients that may be associated with their region of residence. Further investigation of this regional picture as it relates to post-transplant outcomes is needed, according to Dr. Lehr.

Implications for clinical practice

These findings emphasize the need for ongoing study as well as the importance of recognizing these disparities in clinical practice. At Cleveland Clinic, the entire team is aware of this ongoing challenge and works together to mitigate disparities as much as possible.

“In recent years, the Cleveland Clinic and our team have developed an increasing awareness of how systemic the problem is,” notes Dr. Lehr. “When we discuss individual cases in our selection committee, we are very cognizant of discussing potential inequity or potential ways that the health system may have not served our patients.

“We want to be really careful that these factors don’t disadvantage the person in their selection for transplant,” she adds. “We also have a bioethicist in our meeting each week to assist with some of these issues and make sure we’re all thinking about this in an unbiased way. Ongoing discussions, awareness, and honesty between providers are crucial to make sure we don’t unknowingly allow potential bias to impact decision making.”

Moving forward, Dr. Lehr emphasizes the importance of ongoing studies to better understand and address disparities. “Individuals who survive to access transplant are a very selected cohort who have already overcome a number of hurdles, and there are multiple opportunities for these patients to fall out of this pipeline,” she says.

“Our ability to look at the broad population of people with end-stage lung disease has been limited due to a lack of a comprehensive registry,” Dr. Lehr concludes. “And so, future efforts should look at this broad population and see what the breakdown is in terms of racial and ethnic composition as we move through each step. I suspect that it’s quite different, and I believe that when we can find the points in the system where people are falling off, that will help guide us on how to direct our resources.”