Too few rural Georgians being referred for organ transplants

Although Georgia has one of the nation’s most robust organ transport networks, some Atlanta doctors say they want more people in rural parts of the Peach State to gain access to transplant operations.

Many Georgians who might qualify for kidney and liver transplants aren’t being referred by their doctors. Race and gender appear to be acting as barriers to care for rural residents who might qualify for transplants but aren’t being given referrals.

“It’s sad,” said Clark D. Kensinger, multi-organ transplant surgeon at Piedmont Transplant Institute. “The inability to get people from rural Georgia to a transplant center in Atlanta is really evident sometimes.”

To tackle the problem, doctors from Piedmont and Emory are making outreach visits to rural parts of the state, to so-called “referral practices” that send transplant candidates to Atlanta. The goal is to make rural doctors aware of transplant services available in the capital. The importance of the outreach efforts has been underscored by two new data analytics projects showing barriers to transplants.

A study by Jessica Harding of Emory University found that women in the Southeast have a higher prevalence of chronic kidney disease than women elsewhere in the U.S. The study focused specifically on Georgia, North and South Carolina, and found that women in those states are more likely to drop out of the kidney transplant process.

“We think the reasons are more likely to be social in nature,” said Harding, an epidemiologist at the Rollins School of Public Health at Emory University. “Strong hypotheses include unconscious bias. For the same set of conditions, like diabetes, women are less likely to be referred for transplant as compared to men with diabetes.”

Lower levels of insurance, women’s attitudes toward transplants, lower self-advocacy among women, and a lack of awareness of sex and gender disparities among providers could account for the gap, Harding said.

White women in Georgia are receiving lower levels of kidney care than men of all races. Black women are receiving the lowest level of care among all groups. “This is likely due to the intersection between racism and sexism,” Harding said. “Studies have shown that Black women fare worse than other race/sex combinations.”

Moreover, all American women are disadvantaged in another significant way: though they constitute 60% of living kidney donors, less than 40% of people who receive a living donor transplant are women, Harding said. In Georgia, lack of access to insurance may be the driver of such inequities, though sex and gender disparities have also been shown in countries with universal healthcare coverage, like Sweden, she added.

In 2020, the average kidney transplant cost was $442,500, while the average liver transplant cost was $878,400, according to Milliman Research.

A second study by Katherine Ross-Driscoll of Indiana University , who was at Emory when she initiated the research, quantified disparities in access to liver transplants. Her work found that older, poorer, Black and Medicaid beneficiaries in Georgia are less likely to be placed on liver transplant lists than their counterparts.

“Medicaid recipients were half as likely to complete the testing needed to gain referrals compared to people who have private insurance,” Ross-Driscoll said. “If referring practices in Georgia have had the experience that patients with Medicaid aren’t being taken by Emory and Piedmont, that could lead them to stop referring patients. Some future qualitative work where we explore incentives might uncover some of the biases.”

Georgia’s main kidney, liver, and other organ transplant centers are located in Atlanta at Emory University Hospital, Piedmont Hospital, and Children’s Healthcare of Atlanta at Egleston. In Augusta, Wellstar MCG Health performs kidney transplant operations, according to the U.S. Department of Health and Human Services.

Another potential barrier: Some rural general practitioners might simply not be aware that their patients can qualify for transplant operations, said Giorgio Roccaro, Medical Director of the Living Donor Liver Transplant Program at Emory University.

“We see patients who don’t reflect the state’s population,” he said. “We generally see patients from North Georgia who receive expedited referrals. Ross-Driscoll’s work exposed gaps: only about 1/4 of patients who have the option of a curative transplant actually get to see a transplant specialist.”

Roccaro said he and others from Emory organize outreach visits around the state to make primary care doctors aware of the services Emory can offer potential transplant patients. The goal, he said, is to be able to offer transplant operations to a broader array of Georgians.

Roccaro agreed that dental diseases and chronic illnesses can also act as barriers to patients receiving transplant referrals. Chronic dental issues can be especially problematic because a transplant patient must take immunosuppression medicines to stop the body from rejecting a donated organ. Yet this lifesaving tool leads to a higher chance of getting infections, including making the mouth more susceptible to infections that can spread through the body.

“There is a general baseline health issue in Georgia, due to obesity and diabetes,” Roccaro said. “But we are used to this. There are few medical conditions that would prohibit a transplant in totality. Those decisions need to be taken at a place like Emory, where we do 120 liver transplants a year, and evaluate at least three times as many people for transplant.”

As of July 10, 2,934 Georgians are waiting for a transplant organ: 88% await a donor kidney, while 8% hope to receive a liver, according to Norcross-based LifeLink of Georgia, a nonprofit that works with hospitals in Georgia to match organ, tissue, and eye donors with recipients. Nationwide, 103,809 Americans are waiting for donor organs to become available, according to the U.S. government’s Organ Procurement & Transplantation Network (OPTN).

Black and Hispanic/Latino groups are overrepresented on the transplant waitlist compared to their share of the general population. Black individuals make up 27.51% of the national waitlist – double their 12.1% share of the U.S. population. Hispanic/Latino individuals constitute 22.73% of the waitlist, compared to their 18.9% share of the U.S. population.

The disparity is similar in Georgia, said Bobby Howard, Director of the Multicultural Donation Education Program at LifeLink of Georgia. “In Georgia, 60% of people waiting for transplants come from the African American community,” Howard said. “A large number of those patients are waiting for kidneys, and the need is high due to high blood pressure, and other comorbidities in the community.”

Black Georgians comprise 33% of the state’s population, according to the U.S. Census Bureau.

On a Sunday this spring, Howard set up a table at True Light Baptist Church in West Lake, and worked with Rev. Darrell D. Elligan to dispel parishioners’ concerns. “A lot of the questions that I received were typical,” Howard said. “If I register to be an organ donor, and I get into an accident, will the doctors save my life, or let me pass just to take my organs? We know that medical professionals do everything they can to save life. It’s when those efforts fail that organ transplant becomes possible.”

This past semester, LifeLink of Georgia and Morehouse School of Medicine (MSM) also initiated a program to increase interest among Black medical students in transplant surgery, according to a press release on MSM’s website.

Kensinger of Piedmont Hospital says he’s optimistic that Georgia can broaden access to referrals so that patients will be able to have their suitability for transplants judged at one of the state’s main transplant centers.

He’s also encouraged by data showing that wait times for organ transplants have fallen because organ donations have reached record highs nationwide, according to OPTN.

“Three years ago, our wait time was eight years. Right now, it’s less than a year,” he said, adding that his hospital performs 340-350 kidney transplants per year, putting it in the top 10% of hospitals in the U.S., and 140-155 liver transplants per year on average.

He says outreach and training efforts in rural Georgia by his hospital and Emory are helping rural doctors feel confident that they can send more patients to Atlanta.

“Everyone is doing their best job, but as with anything, there are always ways to improve and increase health literacy,” Kensinger said.

“They aren’t overburdening us with these referrals,” he added.

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