1. After reading the article by Thomas et al., comment on where your research, or your research interests, fit into the generational framework for health disparities research. If your work is 1rst or 2nd generation, comment on how your work could lead in the future to 3rd or 4th generation work. If your work is 3rd or 4th generation, comment on what 1rst and 2nd generation work was necessary as a foundation for your current work (or current interests).
My disparities-related research is primarily in the first or second generation. I am interested in geographic disparities in access to liver transplantation and the ways in which these are altered by patients who are able to travel to gain broader access to transplant (which, in and of itself, is a disparity). The broader goal of these efforts is to improve policy that minimizes the role of geography in access to transplant and prioritizes patients based on illness severity or waiting time, instead of location. Third and fourth generation work in this area might include predictive modeling to demonstrate the impact of changes in allocation policy, followed by the actual implementation of new policy. Within the past several months, liver allocation changed to prioritize candidates based on their disease severity and their distance from the transplant center. It will be important to study the effect of this change on allocation-related disparities in the future.
2. The barbershop hypertension intervention, while essentially a clinical services intervention operating at either the fence or safety-net level as described by Jones, has some engagement with the social determinants of health. Interventions like that described in the Gottleib article are designed to mitigate the impact of social determinants. How could you apply one of these two types of interventions to your area of research? Propose one or two interventions that engage with social determinants on some level.
In the space of “travel for transplant” and organ allocation, I don’t think there are many roles for interventions like the barbershop hypertension intervention or the intervention detailed in the Gottleib article. However, a related issue is that of living donor liver transplantation, because if living donor liver transplant were more widespread in the United States, deceased donor organs would not be in such high demand and the ability to travel would not cause such striking disparities in access. In Asia, more than 80% of liver transplants performed each year are from living donors, and some centers perform more than 300 live donor liver transplants per year. In the United States, the climate is exactly opposite, with only about 6% of liver transplants coming from live donors and only 8 centers who routinely perform more than 10 living donor liver transplants each year. The utilization of living donors is highest in regions where there are long waiting list times and extensive competition for deceased donor organs, but there remains incredible potential with live donor liver transplant that we have yet to fully tap into. At UCSF, the majority of living donor liver transplant donors and recipients are white, but a large percentage of our waitlist for liver transplant is made up of Hispanic and Asian candidates. I can envision that outreach in these communities aimed at educating, clarifying and advocating for living donor liver transplant may make the concept more accessible and feasible for these groups.