Racial disparities in access to renal transplantation - Clinically appropriate or due to underuse or overuse?

Background: Despite abundant evidence of racial disparities in the use of s urgical procedures, it is uncertain whether these disparities reflect racia l differences in clinical appropriateness or overuse or underuse of care. Methods: We performed a literature review and used an expert panel to devel op criteria for determining the appropriateness of renal transplantation fo r patients with end-stage renal disease. Using data from five states and th e District of Columbia on patients who had started to undergo dialysis in 1 996 or 1997, we selected a random sample of 1518 patients (age range, 18 to 54 years), stratified according to race and sex. We classified the appropr iateness of patients as candidates for transplantation and analyzed data on rates of referral to a transplantation center for evaluation, placement on a waiting list, and receipt of a transplant according to race. Results: Black patients were less likely than white patients to be rated as appropriate candidates for transplantation according to appropriateness cr iteria based on expert opinion (71 blacks [9.0 percent] vs. 152 whites [20. 9 percent]) and were more likely to have had incomplete evaluations (368 [4 6.5 percent] vs. 282 [38.8 percent], P<0.001 for the overall chi-square). A mong patients considered to be appropriate candidates for transplantation, blacks were less likely than whites to be referred for evaluation, accordin g to the chart review (90.1 percent vs. 98.0 percent, P=0.008), to be place d on a waiting list (71.0 percent vs. 86.7 percent, P=0.007), or to undergo transplantation (16.9 percent vs. 52.0 percent, P<0.001). Among patients c lassified as inappropriate candidates, whites were more likely than blacks to be referred for evaluation (57.8 percent vs. 38.4 percent), to be placed on a waiting list (30.9 percent vs. 17.4 percent), and to undergo transpla ntation (10.3 percent vs. 2.2 percent, P<0.001 for all three comparisons). Conclusions: Racial disparities in rates of renal transplantation stem from differences in clinical characteristics that affect appropriateness as wel l as from underuse of transplantation among blacks and overuse among whites . Reducing racial disparities will require efforts to distinguish their spe cific causes and the development of interventions tailored to address them. (N Engl J Med 2000;343:1537-44.) (C) 2000, Massachusetts Medical Society.