Health Care Perceptions and a Concierge-Based Transplant Evaluation for Patients With Kidney Disease

Abstract

The kidney transplant (KT) evaluation process is particularly time consuming and burdensome for Black patients, who report more discrimination, racism, and mistrust in health care than White patients. Whether alleviating patient burden in the KT evaluation process may improve perceptions of health care and enhance patients' experiences is important to understand. To investigate whether Black and White participants would experience improvements in perceptions of health care after undergoing a streamlined, concierge-based approach to KT evaluation. This prospective cohort study from a single urban transplant center included Black and White English-speaking adults who were referred for KT and deemed eligible to proceed with the KT evaluation process. The patients responded to baseline and follow-up questionnaires. The study was conducted from May 2015 to June 2018. Questionnaires were collected before KT evaluation initiation (baseline) and after KT evaluation completion (follow-up). Data were analyzed from October 2022 to January 2024. Data were stratified by race (Black compared with White) and time (baseline compared with follow-up). The main outcomes were experiences of discrimination in health care, perceived racism in health care, medical mistrust of health care systems, and trust in physician. Repeated-measures regression was used to assess race, time, and the race-by-time interaction as factors associated with each outcome. The study included 820 participants (mean [SD] age, 56.50 [12.93] years; 514 [63%] male), of whom 205 (25%) were Black and 615 (75%) were White. At baseline and follow-up, Black participants reported higher discrimination (119 [58%]; χ21 = 121.89; P < .001 and 77 [38%]; χ21 = 96.09; P < .001, respectively), racism (mean [SD], 2.73 [0.91]; t290.46 = 7.77; P < .001 and mean [SD], 2.63 [0.85]; t296.90 = 7.52; P < .001, respectively), and mistrust (mean [SD], 3.32 [0.68]; t816.00 = 7.29; P < .001 and mean [SD], 3.18 [0.71]; t805.00 = 6.43; P < .001, respectively) scores but lower trust in physician scores (mean [SD], 3.93 [0.65]; t818.00 = -2.01; P = .04 and mean [SD], 3.78 [0.65]; t811.00 = -5.42; P < .001, respectively) compared with White participants. All participants experienced statistically significant reductions in discrimination (Black participants: odds ratio, 0.27 [95% CI, 0.16-0.45]; P < .001; White participants: odds ratio, 0.37 [95% CI, 0.25-0.55]; P < .001) and medical mistrust in health care (Black participants: β [SE], -0.16 [0.05]; P < .001; White participants: β [SE], -0.09 [0.03]; P < .001), and Black participants reported lower perceived racism at follow-up (β [SE], -0.11 [0.05]; P = .04). There was a statistically significant race-by-time interaction outcome in which Black participants' trust in physicians was significantly lower at follow-up, but White participants reported no change. The findings of this cohort study of patients who underwent a streamlined, concierge-based KT evaluation process suggest that a streamlined approach to clinic-level procedures may improve patients' perceptions of the health care system but may not improve their trust in physicians. Future research should determine whether these factors are associated with KT outcome, type of KT received, and time to KT.