Association of Socioeconomic Position With Racial and Ethnic Disparities in Survival After Lung Transplant

Abstract

A recent National Academies of Sciences, Engineering, and Medicine study found that transplant outcomes varied greatly based on multiple factors, including race, ethnicity, and geographic location. They proposed a number of recommendations including studying opportunities to improve equity in organ allocation. To evaluate the role of donor and recipient socioeconomic position and region as a mediator of observed racial and ethnic differences in posttransplant survival. This cohort study included lung transplant donors and recipients with race and ethnicity information and a zip code tabulation area-defined area deprivation index (ADI) from September 1, 2011, to September 1, 2021, whose data were in the US transplant registry. Data were analyzed from June to December 2022. Race, neighborhood disadvantage, and region of donors and recipients. Univariable and multivariable Cox proportional hazards regression were used to study the association of donor and recipient race with ADI on posttransplant survival. Kaplan-Meier method estimation was performed by donor and recipient ADI. Generalized linear models by race were fit, and mediation analysis was performed. Bayesian conditional autoregressive Poisson rate models (1, state-level spatial random effects; 2, model 1 with fixed effects for race and ethnicity, 3; model 2 excluding region; and 4: model 1 with fixed effects for US region) were used to characterize variation in posttransplant mortality and compared using ratios of mortality rates to the national average. Overall, 19 504 lung transplant donors (median [IQR] age, 33 [23-46] years; 3117 [16.0%] Hispanic individuals, 3667 [18.8%] non-Hispanic Black individuals, and 11 935 [61.2%] non-Hispanic White individuals) and recipients (median [IQR] age, 60 [51-66] years; 1716 [8.8%] Hispanic individuals, 1861 [9.5%] non-Hispanic Black individuals, and 15 375 [78.8%] non-Hispanic White individuals) were included. ADI did not mediate the difference in posttransplant survival between non-Hispanic Black and non-Hispanic White recipients; it mediated only 4.1% of the survival difference between non-Hispanic Black and Hispanic recipients. Spatial analysis revealed the increased risk of posttransplant death among non-Hispanic Black recipients may be associated with region of residence. In this cohort study of lung transplant donors and recipients, socioeconomic position and region of residence did not explain most of the difference in posttransplant outcomes among racial and ethnic groups, which may be due to the highly selected nature of the pretransplant population. Further research should evaluate other potentially mediating effects contributing to inequity in posttransplant survival.