Press Releases

2000 Releases

Large Racial Differences in Kidney Transplant Rates Due to Inappropriate Care for Both Black and Whites

For immediate release: November 22, 2000

Boston, MA.-- In the most comprehensive study to date of the factors behind racial differences in the rates of a surgical procedure, Harvard researchers have found that both underuse of kidney transplants for black patients and overuse for white patients contribute to a wide gap in use between the groups. Their paper appears in the Nov. 23 New England Journal of Medicine (

Many studies have identified racial disparities in access to surgical procedures but not the underlying causes. While some have argued that racial disparities mainly reflect broad differences in medical conditions according to race, others have argued that these disparities are mainly due to racially based barriers to the receipt of appropriate care. But researchers led by Arnold Epstein, chairman of the Department of Health Policy and Management at Harvard School of Public Health, studied patients with end-stage renal disease and found a more complex picture that includes these factors and others.

Instead of studying patients on dialysis as a general group, Epstein and colleagues analyzed medical records to distill those patients who under objective measurements could be deemed appropriate for kidney transplant. They then traced the path of treatment decisions for this more uniform group.

"We have never known what were the differences for people who should have gotten the procedure-- only that there were differences among patients in general," said Epstein. "This is a whole new dimension."

Using objective measurements of medical condition that take into account the co-existence of other diseases, the researchers found that about twice as many whites as blacks were rated as appropriate (20.9 percent vs. 9.0 percent); blacks were more likely to have incomplete workups (47% vs 39%). 

"There was a clear difference in the medical condition of the two populations," said Epstein, "such as the higher proportion of blacks with hypertension while whites had high rates of coronary heart disease and diabetes mellitus."

Still, among those patients rated appropriate, for whom a procedure was warranted there were significant differences by race at points all along the treatment path to transplantation: 

    • Referral to a transplantation center for evaluation (98 percent of whites vs. 79 percent of blacks);
    • Wait listing (87 percent vs. 71 percent) 
    • Transplantation (52 percent vs. 17 percent). 
Among patients rated inappropriate for a transplant procedure there were also large racial disparities:
    • Referral for transplant evaluation(52 percent of whites vs. 34 percent of blacks);
    • Wait listing (31 percent vs. 17 percent)
    • Transplantation (10 percent vs. 2 percent).
"We have known about racial disparities in care and health outcomes for a long time, and they still persist," said Epstein. "We have failed to galvanize change in part because no one knew for sure what the disparities meant." The study results, he said, "show that we should not expect equal rates by race. At the same time, some of the racial disparity is due to overuse of transplantation for whites and some to underuse for blacks among patients for whom the procedure is warranted. The barriers that account for underuse for blacks occur at various points in evaluation and treatment. Intervening at just one point is not going to close the gap. This is a complex picture."

The study’s co-authors are John Ayanian, MD, MPP, Associate Professor of Medicine and of Health Care Policy at Harvard Medical School and Brigham and Women’s Hospital, Joseph Keogh, MD, JD, and Susan Noonan MD, MPH, of CliGnosis Inc, Nancy Armistead, MPA, Paul Cleary, PhD, Professor of Health Care Policy at Harvard Medical School and Joel Weissman, PhD, Assistant Professor of Medicine at Massachusetts General Hospital, Jo Ann David-Kasdan, RN, MS, Diane Carlson, Jerry Fuller, MSW, Douglas Marsh and Rena Conti..

Graphs are available from the Office of Communications at the Harvard School of Public Health, 617-432-4388.

The study was funded by the Robert Wood Johnson Foundation.

For further information, please contact:

Robin Herman
Office of Communications
Harvard School of Public Health
677 Huntington Avenue
Boston, MA 02115
Phone: 617-432-4752