1) How do individual physicians contribute to health care disparities? Thinking about an area of health care of particular interest to you, what research do you think could be done to either understand the effect of individual physicians on health disparities, or to decrease this effect?
Implicit bias continues to contribute to significant health disparities in the United States. In the field of pediatric nephrology specifically, there are significant disparities in access to preemptive transplant when comparing white children to all other minority groups. Preemptive transplant is the treatment modality of choice for pediatric patients with late stage chronic kidney disease as avoiding dialysis is associated with better cognitive and developmental outcomes in this population. Studies have shown that these disparities are due to a number of factors, but there is suspicion that implicit bias may be contributing. Limited studies have found that providers are less likely to discuss preemptive transplant and living donation with minority families, and low income minority families in particular. More careful and intensive studies of how physicians discuss transplant and donation with patients of different racial/ethnic and socioeconomic groups would be useful in eliciting how much physician bias is impacting access to preemptive transplant compared to other social and cultural factors.
2) Structural issues within health care delivery are implicated in health care disparities. Please brainstorm 4 structural issues that might contribute to these disparities. Which of these are relevant to your particular area of research, and how?
Lack of access to paid family leave is a major area of disparity in pediatric transplant and in access to preemptive transplant. In studies that examined specific barriers to living donation between parent and child, one of the largest contributors was financial concerns related to missing work. This contributes to lower rates of preemptive transplant and worse posttransplant outcomes among minority and low income pediatric patients.
Another major structural disparity with regards to pediatric preemptive transplant is poor access to health care services or low quality health insurance plans for caregivers. Fortunately, children with chronic disease are covered under state sponsored health insurance, however their parents are not. Because donating an organ involves a significant surgical procedure and necessitates life-long medical follow up, many parents do not donate due to concerns for their own health.
Language barriers are another significant contributor to health disparities among pediatric renal transplant patients. Patients and their families have a right to an interpreter in their language of choice. However, interpreter services are expensive and most clinics to not allot extra time for visits that necessitate an interpreter, even though information takes longer to convey. This may lead to rushed visits and worse care for patients who utilize interpreter services. In this situation, families may not fully understand the benefits of preemptive transplant or what criteria they need to meet to donate to their children.
Immigration concerns are another cause of disparities in access to preemptive transplant. Parents who are undocumented are much less likely do donate a kidney to their children due to concerns about access to medical care after donation. Additionally, donors are registered in the United States Renal Data System database, and so undocumented family members may be concerned about legal implications to donation. Additionally, transplant in undocumented children is challenging, given their often uncertain status.