Blacks with chronic obstructive pulmonary disease (COPD) were less likely to receive a lung transplant and more likely to die or be removed from the transplant list than whites, according to Columbia University Medical Center researchers.
"These disparities are consistent with those observed among patients awaiting kidney and liver transplantation and among patients with other advanced lung diseases such as pulmonary arterial hypertension and pulmonary fibrosis," wrote lead researcher, David Lederer, M.D., M.S., of Columbia University Medical Center. "This finding was independent of age, lung function, cardiovascular risk factors, transplant center volume, type of health insurance coverage, and neighborhood poverty level."
The researchers retrospectively assessed the entire cohort of 280 non-Hispanic black adults and 5,272 non-Hispanic white adults diagnosed with COPD or emphysema who were awaiting lung transplantation on the United Network for Organ Sharing (UNOS) list between January 1, 1995 and December 31, 2004. The investigators tracked the outcomes (death, transplantation, removal from the list, or still living) of the transplant-awaiting patients to the end of the study period and analyzed the results with respect to age, sex, disease severity, community poverty level and transplant center volume.
"We have shown that black patients with COPD were less likely to undergo lung transplantation after listing than white patients in the United States during the late 1990's and the early 2000's," wrote Dr. Lederer.
The researchers did find that blacks were also less likely to have private insurance and more likely to live in poorer neighborhoods and have greater cardiovascular risk factors, such as diabetes, pulmonary hypertension and lower six-minute walk distances than whites. However, even these factors did not account for the findings.
"Differences in insurance, socioeconomic status and cardiovascular risk factors explained some but not all of the higher risk of death or removal from the waiting list," said Dr. Lederer.
In the post-hoc analysis, the researchers also found that Hispanics had similar outcomes to non-Hispanic blacks.
Strikingly, only 280 black and 64 Hispanic patients with COPD were put on the lung transplant waiting list in the United States during the 10-year study period. "Based on what we know about COPD, we expected that twice as many black patients would have been put on the ling transplant waiting list. Our findings point to significant barriers to accessing lung transplantation for minorities," said Dr. Lederer.
For physicians, the implications of this research are clear. "These findings should alert primary care physicians and pulmonologists to consider referral of black patients with COPD for transplantation at the earliest signs of advanced disease."
To protect themselves from these disparities, "patients with COPD should prepare themselves for transplantation by discussing all of their treatment options with their doctor. To be eligible for lung transplantation, patients must quit smoking, use medications and oxygen as prescribed, and participate in a pulmonary rehabilitation program to increase their strength and endurance," said Dr. Lederer.
While the organ allocation system in place during the study period has been replaced with one that prioritizes patients based on the survival benefit of transplantation, Dr. Lederer cautions, the effects of poor insurance and poverty will likely still place blacks at increased risk for removal from the list or death.
"The next step will be to identify the specific barriers that patients encounter, while trying to get on the waiting list for a lung transplant. Once we figure out the root of the problem, we can begin to improve access for all patients with COPD."
The findings were published in the second issue for February of the American Journal of Respiratory and Critical Care Medicine, published by the American Thoracic Society.
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