November 2009 - Physician bias might be the reason why African Americans are not receiving kidney/pancreas transplants at the same rate as similar patients in other racial groups. Dr. Keith Melancon, director of kidney and pancreas transplantation at Georgetown University Hospital and associate professor of surgery at Georgetown University Medical Center, and colleagues explore this phenomenon in the November issue of the American Journal of Transplantation.
Medicare coverage for people needing a simultaneous kidney/pancreas transplant has increased in the past decade. In July 1999 Medicare made the changes as a conscious effort by the government intended to address racial and economic disparities that existed. But increased Medicare dollars have not translated into more access for African Americans or Hispanics.
"Our research raised the possibility of racial bias on the part of physicians who might incorrectly assume that African Americans are type 2 diabetics when in fact, they would metabolically meet the criteria for type 1 diabetes," said Dr. Melancon.
"Since this is a transplant that is most often performed in type 1 diabetics, their doctors might not even raise the possibility with their black patients. Also, health care providers might incorrectly predict worse outcomes for black patients, despite research that shows they do about as well as other racial groups."
Dr. Melancon's group took a look at the national transplant list before and after the Medicare changes in July 1999. Of the patients already listed for transplant, African Americans were 27% less likely to be recommended for a kidney pancreas transplant than Caucasians. Hispanics were 25% less likely to be recommended. After the Medicare changes African Americans were 28% less likely to be recommended for kidney/pancreas transplant and Hispanics were 31% less likely to be recommended.
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"So, the situation for African Americans and Hispanics actually got worse instead of better," said Dr. Melancon.
The benefits of a kidney pancreas transplant are the list is much shorter; 2200 compared with over 80,000 for a kidney alone, according to the United Network of Organ Sharing (www.unos.org). Patient survival and kidney graft survival are better in kidney pancreas transplants.
"I don't think the medical community has been aggressive enough about kidney/pancreas transplant, especially in African Americans who are assumed to have type 2 diabetes. When a person has type 2 diabetes and they are obese, the benefit of a kidney/pancreas transplant is often outweighed by the risks of surgery which are higher in an obese person. So they are not offered the transplant.
There is also a population of people with diabetes who are sort of between type 1 and type 2. This procedure would work for them too. But I think the medical community is, in some cases, making assumptions about the African American and Hispanic population that they are not making with other racial groups."
A kidney/pancreas transplant is the only current, reliable way to give diabetics normal glucose and insulin levels 24 hours a day. It's not technically a cure, but it does eliminate the medical problems associated with diabetes.
Source: Georgetown University Medical Center
