Neighborhood socioeconomic deprivation, racial segregation, and organ donation across 5 states

Abstract

One in 10 people die awaiting transplantation from donor shortage. Only half of Americans register as organ donors. In this cross-sectional study, we evaluated population-level associations of neighborhood socioeconomic deprivation and racial segregation on organ donor registration rates. We analyzed state identification card demographic and organ donor registration data from 5 states to estimate the association between a neighborhood socioeconomic deprivation index (range [0, 1]; higher values indicate more deprivation) and a racial index of concentration at the extreme (ICE) (range [–1, 1]; lower values indicate predominantly black neighborhoods, higher values indicate predominantly white neighborhoods) on organ donor registration rates within a specified geography (census tract or ZIP code tabulation area [ZCTA]). Among 26 720 738 registrants, 32% of the sample were registered organ donors. At the census tract level, with each 0.1 decrease in the deprivation index, the organ donor registration rate increased by 6.8% (95% confidence interval [CI]: 6.6%, 7.0%). With each 0.1 increase in the racial ICE, the rate increased by 1.5% (95% CI: 1.5%, 1.6%). These associations held true at the ZCTA level. Areas with less socioeconomic deprivation and a higher concentration of white residents have higher organ donor registration rates. Public health initiatives should consider neighborhood context and novel data sources in designing optimal intervention strategies. One in 10 people die awaiting transplantation from donor shortage. Only half of Americans register as organ donors. In this cross-sectional study, we evaluated population-level associations of neighborhood socioeconomic deprivation and racial segregation on organ donor registration rates. We analyzed state identification card demographic and organ donor registration data from 5 states to estimate the association between a neighborhood socioeconomic deprivation index (range [0, 1]; higher values indicate more deprivation) and a racial index of concentration at the extreme (ICE) (range [–1, 1]; lower values indicate predominantly black neighborhoods, higher values indicate predominantly white neighborhoods) on organ donor registration rates within a specified geography (census tract or ZIP code tabulation area [ZCTA]). Among 26 720 738 registrants, 32% of the sample were registered organ donors. At the census tract level, with each 0.1 decrease in the deprivation index, the organ donor registration rate increased by 6.8% (95% confidence interval [CI]: 6.6%, 7.0%). With each 0.1 increase in the racial ICE, the rate increased by 1.5% (95% CI: 1.5%, 1.6%). These associations held true at the ZCTA level. Areas with less socioeconomic deprivation and a higher concentration of white residents have higher organ donor registration rates. Public health initiatives should consider neighborhood context and novel data sources in designing optimal intervention strategies. Currently, 114 411 people await lifesaving organ transplants. In 2017, 12 093 people died or were removed from the waitlist for being too sick for transplantation, representing 11% of those waitlisted.1National Data - OPTN. Published September 24, 2019. https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/#. Accessed September 24, 2019.Google Scholar There continue to be geographic,2Goldberg DS French B Forde KA et al.Association of distance from a transplant center with access to waitlist placement, receipt of liver transplantation, and survival among US veterans.JAMA. 2014; 311: 1234-1243Crossref PubMed Scopus (99) Google Scholar socioeconomic,3Braun HJ Perito ER Dodge JL Rhee S Roberts JP. Nonstandard exception requests impact outcomes for pediatric liver transplant candidates.Am J Transplant. 2016; 16: 3181-3191Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar and racial disparities4Ross K Patzer RE Goldberg DS Lynch RJ. Sociodemographic determinants of waitlist and posttransplant survival among end-stage liver disease patients.Am J Transplant. 2017; 17: 2879-2889Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar among those who die. Disparities in organ allocation may contribute to disparities in outcomes. Although organ donation rates have increased, demand continues to exceed supply.5Israni AK Zaun D Rosendale JD Schaffhausen C Snyder JJ Kasiske BL. OPTN/SRTR 2017 annual data report: deceased organ donation.Am J Transplant. 2019; 19: 485-516Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar In the United States, approximately 70% of the population are willing to donate their organs,6Siminoff LA Gordon N Hewlett J Arnold RM. Factors influencing families’ consent for donation of solid organs for transplantation.JAMA. 2001; 286: 71-77Crossref PubMed Scopus (499) Google Scholar,7Siminoff LA Burant CJ Ibrahim SA. Racial disparities in preferences and perceptions regarding organ donation.J Gen Intern Med. 2006; 21: 995-1000Crossref PubMed Scopus (130) Google Scholar yet only 56% of eligible adults register as organ donors on their state drivers’ license or identification card.5Israni AK Zaun D Rosendale JD Schaffhausen C Snyder JJ Kasiske BL. OPTN/SRTR 2017 annual data report: deceased organ donation.Am J Transplant. 2019; 19: 485-516Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar,8Donate Life America. Donate Life America Annual Report. 2019.Google Scholar,9Traino HM Siminoff LA. Attitudes and acceptance of First Person Authorization: a national comparison of donor and nondonor families.J Trauma Acute Care Surg. 2013; 74: 294-300Crossref PubMed Scopus (33) Google Scholar Without clearly demarcated donor status, only half of families approached at the time of a potential donor’s death consent to donating their loved one’s organs.6Siminoff LA Gordon N Hewlett J Arnold RM. Factors influencing families’ consent for donation of solid organs for transplantation.JAMA. 2001; 286: 71-77Crossref PubMed Scopus (499) Google Scholar Identifying subgroups with low rates of organ donor registration may enable tailored public health initiatives to increase registration rates.10Bayer R Galea S. Public health in the precision-medicine era.N Engl J Med. 2015; 373: 499-501Crossref PubMed Scopus (154) Google Scholar At an individual level, those with lower socioeconomic status and African Americans are less likely to register as organ donors.7Siminoff LA Burant CJ Ibrahim SA. Racial disparities in preferences and perceptions regarding organ donation.J Gen Intern Med. 2006; 21: 995-1000Crossref PubMed Scopus (130) Google Scholar,11Sehgal NKR Scallan C Sullivan C et al.The relationship between verified organ donor designation and patient demographic and medical characteristics.Am J Transplant. 2016; 16: 1294-1297Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar,12Goldberg DS Halpern SD Reese PP. Deceased organ donation consent rates among racial and ethnic minorities and older potential donors.Crit Care Med. 2013; 41: 496-505Crossref PubMed Scopus (80) Google Scholar Community-based interventions have been heralded as important tools for increasing organ donor registration,13Deedat S Kenten C Morgan M. What are effective approaches to increasing rates of organ donor registration among ethnic minority populations: a systematic review.BMJ Open. 2013; 3 (e003453.)Crossref PubMed Scopus (34) Google Scholar,14Andrews AM Zhang N Magee JC Chapman R Langford AT Resnicow K. Increasing donor designation through black churches: results of a randomized trial.Prog Transplant. 2012; 22: 161-167Crossref PubMed Scopus (27) Google Scholar yet links between neighborhood contextual characteristics, enumerated using area-level data, and registration have been minimally explored.15Grubesic TH. Driving donation: a geographic analysis of potential organ donors in the state of Ohio, USA.Soc Sci Med. 2000; 51: 1197-1210Crossref PubMed Scopus (17) Google Scholar, 16Ladin K Wang R Fleishman A Boger M Rodrigue JR. Does social capital explain community-level differences in organ donor designation?.Milbank Q. 2015; 93: 609-641Crossref PubMed Scopus (15) Google Scholar, 17Shacham E Loux T Barnidge EK Lew D Pappaterra L. Determinants of organ donation registration.Am J Transplant. 2018; 18: 2798-2803Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Ladin et al16Ladin K Wang R Fleishman A Boger M Rodrigue JR. Does social capital explain community-level differences in organ donor designation?.Milbank Q. 2015; 93: 609-641Crossref PubMed Scopus (15) Google Scholar found that lower area-level social capital (ie, “features of social organization, such as networks, norms, and trust that facilitate coordination and cooperation for mutual benefit”18Putnam RD. The prosperous community: social capital and public life.Am Prospect. 1993; 13: 35-42Google Scholar) and educational attainment were both associated with lower donor registration rates across Massachusetts. However, no other studies have evaluated the association between registration rates and additional ecological factors like socioeconomic deprivation and racial segregation, relevant characteristics at an individual level. Geospatial methods, and area-level data, are routinely employed to target public health interventions to the correct demographic.19Krieger N Chen JT Waterman PD Rehkopf DH Subramanian SV. Race/ethnicity, gender, and monitoring socioeconomic gradients in health: a comparison of area-based socioeconomic measures–the public health disparities geocoding project.Am J Public Health. 2003; 93: 1655-1671Crossref PubMed Scopus (534) Google Scholar, 20Beck AF Sandel MT Ryan PH Kahn RS. Mapping neighborhood health geomarkers to clinical care decisions to promote equity in child health.Health Aff. 2017; 36: 999-1005Crossref PubMed Scopus (60) Google Scholar, 21Miranda ML Dolinoy DC Overstreet MA. Mapping for prevention: GIS models for directing childhood lead PubMed Scopus Google Scholar, ML J B B RM. health a to the Aff. 2013; Scopus (60) Google Scholar, B B et the childhood in the J Public Health. PubMed Scopus Google Scholar, S N K to target and 2014; PubMed Scopus Google Scholar an to of organ donor registration rates across on the of Ladin et K Wang R Fleishman A Boger M Rodrigue JR. Does social capital explain community-level differences in organ donor designation?.Milbank Q. 2015; 93: 609-641Crossref PubMed Scopus (15) Google Scholar and using data on people from 5 state of we between area-based rates of organ donor registration and area-level of socioeconomic deprivation and racial We that with less deprivation and lower of African Americans have higher registration rates. We a cross-sectional using data from drivers’ license and state identification from and We states were across the and for data with the In state we and organ donor registration of ZIP and organ donor registration data were or 26 720 738 The this ZIP were their census tract or ZIP code tabulation area using C C T J Ryan and geocoding and of and for 2018; PubMed Scopus (33) Google Scholar were their be with to the within a or of or their less C C T J Ryan and geocoding and of and for 2018; PubMed Scopus (33) Google Scholar are to be a ZIP for population-level health studies of their geographic and N Waterman Chen JT Subramanian code to between and US geographic Public Disparities J Public Health. PubMed Scopus Google Scholar However, only ZIP we census for their we ZIP to to ZIP and enable to relevant US Published September 2019. Accessed Scholar the of organ donor within a census tract We this by the of organ donor in a census by the of who registered with the within that census were ecological of socioeconomic deprivation and racial were an index of area-based socioeconomic Ryan deprivation and the of an Scholar, AF J socioeconomic deprivation associated with patient and survival pediatric liver transplantation J Transplant. Full Text Full Text PDF PubMed Scopus Google Scholar, et between socioeconomic deprivation and the for liver transplantation Scholar and a racial index of concentration at the N Waterman PD Chen JT segregation association of census tract to with and and using the index of concentration at the (ICE) for and segregation, Health. 2017; Google Scholar both at census tract and ZCTA The socioeconomic deprivation index of from the US and of the population the level, adults with a public population with no health and that are Ryan deprivation and the of an Scholar The index a of [0, 1]; values to indicate with more socioeconomic The racial area-based racial by et N Chen JT Waterman PD Rehkopf DH Subramanian SV. Race/ethnicity, gender, and monitoring socioeconomic gradients in health: a comparison of area-based socioeconomic measures–the public health disparities geocoding project.Am J Public Health. 2003; 93: 1655-1671Crossref PubMed Scopus (534) Google Scholar to health within a specified geography by the of the and across a specified social In with by et N Waterman PD Chen JT segregation association of census tract to with and and using the index of concentration at the (ICE) for and segregation, Health. 2017; Google Scholar as a social from that are socioeconomic The for the racial within a specified geography the between the of white residents and the of black residents by the of white or black These were are at the of racial across the United and for monitoring on the of N Waterman PD Chen JT segregation association of census tract to with and and using the index of concentration at the (ICE) for and segregation, Health. 2017; Google AF C Kahn RS. disparities in rates across and Aff. 2018; 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Factors influencing families’ consent for donation of solid organs for transplantation.JAMA. 2001; 286: 71-77Crossref PubMed Scopus (499) Google Scholar,7Siminoff LA Burant CJ Ibrahim SA. Racial disparities in preferences and perceptions regarding organ donation.J Gen Intern Med. 2006; 21: 995-1000Crossref PubMed Scopus (130) Google Scholar,12Goldberg DS Halpern SD Reese PP. Deceased organ donation consent rates among racial and ethnic minorities and older potential donors.Crit Care Med. 2013; 41: 496-505Crossref PubMed Scopus (80) Google LA disparities in donor and differences in to donate and PubMed Scopus Google Scholar data to of determinants of organ donor TH. Driving donation: a geographic analysis of potential organ donors in the state of Ohio, USA.Soc Sci Med. 2000; 51: 1197-1210Crossref PubMed Scopus (17) Google Scholar, 16Ladin K Wang R Fleishman A Boger M Rodrigue JR. Does social capital explain community-level differences in organ donor designation?.Milbank Q. 2015; 93: 609-641Crossref PubMed Scopus (15) Google Scholar, 17Shacham E Loux T Barnidge EK Lew D Pappaterra L. Determinants of organ donation registration.Am J Transplant. 2018; 18: 2798-2803Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar registration rates were to the in be an registered donors from 5 states a increase in donors across a increase in organ donor registration rates in additional registered Life America. Donate Life America Annual Report. 2019.Google Scholar an increase to the between organ and an increasing rates in low registration may lead to in organ we consider public we in the relationship between socioeconomic deprivation and organ donor registration their socioeconomic and racial using only and at both the and were from we that the in to or ecological differences between and other lower rates of registration across of socioeconomic Ladin et al16Ladin K Wang R Fleishman A Boger M Rodrigue JR. Does social capital explain community-level differences in organ donor designation?.Milbank Q. 2015; 93: 609-641Crossref PubMed Scopus (15) Google Scholar that social capital in organ donor registration rates in Massachusetts. that differences in social capital across the states in explain differences between models with and in a by the US of in America. US Accessed Scholar and lower rates of social capital and In we that residents of and the rates of organ donor We that of area socioeconomic deprivation and social capital neighborhood in with those by et C et al.Association of neighborhood characteristics with Engl J Med. 2012; PubMed Scopus Google Scholar who that are less likely to in black to white may be by that are likely and may trust in the organ LA Burant CJ Ibrahim SA. Racial disparities in preferences and perceptions regarding organ donation.J Gen Intern Med. 2006; 21: 995-1000Crossref PubMed Scopus (130) Google Scholar and from the to are the public organ A of the Public Health. PubMed Scopus Google Scholar in a study, African Americans in organ donation and the LA Burant CJ Ibrahim SA. Racial disparities in preferences and perceptions regarding organ donation.J Gen Intern Med. 2006; 21: 995-1000Crossref PubMed Scopus (130) Google Scholar studies people from more are less likely to register for organ donation may for interventions to registration rates. we are to increased registration rates for organ donation that across we demand that the health trust with and of by LA and trust in the health care 2003; PubMed Scopus Google Scholar, J the the of and of among African PubMed Scopus Google Scholar, and of PubMed Scopus Google Scholar and public health initiatives be employed to increase registration rates across One be to the of as organ donors RE comparison of deceased and organ rates in and a Med. 2014; PubMed Scopus Google Scholar neighborhood context and data tailored public health to increase registration across that organ donor registration interventions and to register have rates of S Kenten C Morgan M. What are effective approaches to increasing rates of organ donor registration among ethnic minority populations: a systematic review.BMJ Open. 2013; 3 (e003453.)Crossref PubMed Scopus (34) Google Scholar such interventions in and the of such M. A systematic of of intervention on rates of organ donor Transplant. 2017; PubMed Scopus Google Scholar data may health and to public health to target of the population less likely to register as donors. as are by public health to disease and ML M J L. disease on the GIS in state and health 2013; PubMed Scopus (17) Google Scholar we be to organ donation rates. we to organ more and public health data may to registration rates. public health interventions have been to disease and S. in public Public Health. 2018; PubMed Scopus (99) Google Scholar, D S. to public 2016; Scopus Google Scholar, public health for the of J Med. 2016; Full Text Full Text PDF PubMed Scopus Google Scholar studies state data have only been NKR Scallan C Sullivan C et al.The relationship between verified organ donor designation and patient demographic and medical characteristics.Am J Transplant. 2016; 16: 1294-1297Abstract Full Text Full Text PDF PubMed Scopus (18) Google TH. Driving donation: a geographic analysis of potential organ donors in the state of Ohio, USA.Soc Sci Med. 2000; 51: 1197-1210Crossref PubMed Scopus (17) Google Scholar, 16Ladin K Wang R Fleishman A Boger M Rodrigue JR. Does social capital explain community-level differences in organ donor designation?.Milbank Q. 2015; 93: 609-641Crossref PubMed Scopus (15) Google Scholar, 17Shacham E Loux T Barnidge EK Lew D Pappaterra L. Determinants of organ donation registration.Am J Transplant. 2018; 18: 2798-2803Abstract Full Text Full Text PDF PubMed Scopus (13) Google M C S in donor Transplant. 2016; PubMed Scopus Google Scholar and may be this population-level associated with organ donor registration across states a novel to organ In with public health (ie, the intervention to the population at the R Galea S. Public health in the precision-medicine era.N Engl J Med. 2015; 373: 499-501Crossref PubMed Scopus (154) Google Scholar initiatives in the of organ and in the United States, outcomes for those awaiting organ we data from 5 to the data the of organ donor registration rates. to in organ donor registration across states and associations with contextual by et M C S in donor Transplant. 2016; PubMed Scopus Google Scholar of characteristics associated with with low rates of organ donors. Although this enumerated important socioeconomic and racial the that their may be to the of the United for census tract in the United and of models the of studies on organ donor registration of to by the of an of donor status on drivers’ or state identification across we were to to census tract data, an to area-based N Waterman Chen JT Subramanian code to between and US geographic Public Disparities J Public Health. 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