Departments of Occupational Therapy and Community, Tufts University, Medford, Massachusetts, USA.
Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, Massachusetts, USA.
J Med Ethics. 2018 Oct;44(10):666-674. doi: 10.1136/medethics-2017-104695. Epub 2018 Jun 28.
National guidelines require programmes use subjective assessments of social support when determining transplant suitability, despite limited evidence linking it to outcomes. We examined how transplant providers weigh the importance of social support for kidney transplantation compared with other factors, and variation by clinical role and personal beliefs.
The National survey of the American Society of Transplant Surgeons and the Society of Transplant Social Work in 2016. Using a discrete choice approach, respondents compared two hypothetical patient profiles and selected one for transplantation. Conditional logistic regression estimated the relative importance of each factor; results were stratified by clinical role (psychosocial vs medical/surgical providers) and beliefs (outcomes vs equity).
Five hundred and eighy-four transplant providers completed the survey. Social support was the second most influential factor among transplant providers. Providers were most likely to choose a candidate who had social support (OR=1.68, 95% CI 1.50 to 1.86), always adhered to a medical regimen (OR=1.64, 95% CI 1.46 to 1.88), and had a 15 years life expectancy with transplant (OR=1.61, 95% CI 1.42 to 1.85). Psychosocial providers were more influenced by adherence and quality of life compared with medical/surgical providers, who were more influenced by candidates' life expectancy with transplant (p<0.05). For providers concerned with avoiding organ waste, social support was the most influential factor, while it was the least influential for clinicians concerned with fairness (p<0.05).
Social support is highly influential in listing decisions and may exacerbate transplant disparities. Providers' beliefs and reliance on social support in determining suitability vary considerably, raising concerns about transparency and justice.
国家指南要求方案在确定移植适宜性时使用社会支持的主观评估，尽管将其与结果联系起来的证据有限。我们研究了移植提供者如何权衡社会支持对肾移植的重要性与其他因素，以及临床角色和个人信念的差异。
2016 年对美国移植外科医生学会和移植社会工作者学会进行了全国调查。使用离散选择方法，受访者比较了两个假设的患者概况，并选择了一个进行移植。条件逻辑回归估计了每个因素的相对重要性；结果按临床角色（心理社会与医疗/外科提供者）和信念（结果与公平）进行分层。
584 名移植提供者完成了调查。社会支持是移植提供者的第二大最有影响力的因素。提供者最有可能选择有社会支持的候选人（OR=1.68，95%CI 1.50-1.86），始终遵守医疗方案（OR=1.64，95%CI 1.46-1.88），并且在移植后有 15 年的预期寿命（OR=1.61，95%CI 1.42-1.85）。与医疗/外科提供者相比，心理社会提供者更受遵守和生活质量的影响，而医疗/外科提供者更受候选人移植后预期寿命的影响（p<0.05）。对于避免器官浪费的提供者来说，社会支持是最有影响力的因素，而对于关注公平的临床医生来说，社会支持的影响力最小（p<0.05）。
社会支持在列表决策中具有高度影响力，可能会加剧移植差异。提供者在确定适宜性时的信念和对社会支持的依赖差异很大，这引发了对透明度和公正性的关注。
