Social support may unduly influence transplant candidacy

Last Updated: 2018-07-06

By Marilynn Larkin

NEW YORK (Reuters Health) - Social support is "highly influential" in transplant listing decisions and may exacerbate disparities, leading many providers to support revised criteria and guidelines, according to two recent studies.

Dr. Keren Ladin of Tufts University in Medford, Massachusetts, lead investigator for both studies, told Reuters Health the investigations were done simultaneously, looking at two different aspects of social support in transplantation decisions.

"Social support is an exclusionary criterion that is not evidence-based," Dr. Ladin told Reuters Health by email. "Studies have not demonstrated that this criterion is predictive of better medication adherence or outcomes post-transplant."

Providers often cite social support as a "hurdle" in the transplant selection process, she noted. "This struck me as odd, given the lack of evidence demonstrating (its) importance. Moreover, in other areas of healthcare, we do not exclude patients from life-saving treatment merely because they do not have friends or family available."

"Conditioning a person's ability to pursue life-saving treatment on social factors is ethically problematic," she said.

One of the studies examined factors associated with providers' perception that social support should be used as a criterion and is fair. A total of 584 kidney transplant providers completed a survey in which they compared two hypothetical patient profiles and selected one for transplantation.

As reported online June 28 in the Journal of Medical Ethics, providers were most likely to choose a candidate who had social support (odds ratio, 1.68), always adhered to a medical regimen (OR, 1.64), and had a 15-year life expectancy with transplant (OR, 1.61).

Psychosocial providers were more influenced by adherence and quality of life compared with medical/surgical providers, who were more influenced by candidates' life expectancy with transplant.

Most providers (71.5%) thought social support was important for ensuring the transplanted organ didn't go to waste, yet nearly one in four (24%) thought using this criterion was unfair; 42.5% didn't feel confident applying this criterion to the selection process.

"Providers who perceived their center's policies for evaluating social support were clear and consistent were 2.29 times more likely to perceive the criteria as fair," Dr. Ladin said. "Moreover, respondents at centers that always informed patients when social support contributes to negative listing decisions had 2.34 greater odds of perceiving the criteria as fair."

The other study polled 551 providers (47% psychosocial, 53% surgical/medical) in multiple organ programs from 202 U.S. centers. Providers were involved in kidney transplantation (72.6%), liver (53%), pancreas (39.9%), heart (13.4%) and lung (7.8%)

The results of the study, online June 7 in the American Journal of Transplantation, "echo the findings in the kidney-only sample," Dr. Ladin said.

On average, 9.6% of patients evaluated in the previous year were excluded due to inadequate support. There was significant variation in use of social support as a criterion by UNOS Region (7.6% to 12.2%) and by center (21.7% in the top quartile). Further, significantly more providers used social support in listing decisions than believed it ought to be used (86.3% vs. 67.6%). More than two-thirds (69.2%) supported revised guidelines for use of social support in listing decisions.

"Our studies demonstrate that providers overwhelmingly . . . want these criteria to be reformed and that approaches to evaluating social support be standardized," Dr. Ladin said. "Most providers did not think that guidelines from the Centers for Medicare and Medicaid Services related to social support evaluations were clear, and many providers thought their own center's social support evaluations were not neutral or impartial."

Dr. Nabil Dagher, Director of Abdominal Transplant Surgery at the NYU Langone Transplant Institute in New York City, told Reuters Health, "There is absolutely no question that transplant patients need social support in order to successfully recover and thrive after transplant - surgery is only the beginning of a lifelong journey."

"Especially early on, patients need help with taking medications, frequent clinic visits, making meals and many other activities of daily living," he said by email. "Most would agree that in the United States, transplanting a patient with no social support would simply be irresponsible."

"Inequalities absolutely do exist but, in this instance, they are more a consequence of a broken and unforgiving healthcare system and not of organ allocation policy in general," he said. "Guidelines for what is acceptable social support may help 'standardize' policy across transplant programs but they will have to take into account the overall healthcare system in which we work."

"Health care systems like those in Canada and across the EU can have less stringent support requirements," he noted, "because they offer universal health care with robust government funded social services to ensure that patients have the support they need after transplant, regardless of socioeconomic status."

SOURCES:

http://bit.ly/2zgnD2p, J Med Ethics 2018.

http://bit.ly/2zfSGuW, Am J Transplant 2018