Blacks as donors for transplantation: suboptimal outcomes overcome by transplantation into other minorities.

BACKGROUND: In 1977, Opelz et al (Transplant Proc 9:137, 1977) introduced research that identified ethnic disparities in the relative risk of graft loss when African American donors or recipients were targeted. Current research from the Organ Procurement and Transplantation Network (OPTN) reveals a continuation of these trends. While 1-year graft survival rates for a kidney are 92.1% for Caucasians, 94.1% for Asians, and 92.9% for Latinos, the comparative rate is 88.9% for African Americans. This study extends research on health disparities by examining relative differences in graft and patient survival rates when the organ donors are African American. A number of factors have been introduced as possible determinants of disparate outcomes by ethnicity in terms of graft survival rates. This descriptive study was designed to test the hypothesis: There are no differences in the relative risks associated with graft survival rates and mortality based upon differences in the ethnicity of the donors. MATERIALS AND METHODS: Data were obtained from the OPTN/United Network for Organ Sharing (UNOS) Registry from April 1, 1994 to December 31, 2000. A total of 118,769 transplants were analyzed, including 77,689 living and deceased donor kidney transplants, 26,124 deceased donor liver transplants, and 14,956 deceased donor heart transplants. A multivariate Cox regression model was used to determine the relative risk of graft loss and cardiac transplant mortality for different ethnicities when the organ donors were African American. RESULTS: The study found that the relative risk of kidney graft loss was 21.3% (P < .01) higher between African American donors and Caucasian recipients than between Caucasian donors and other recipients. With liver transplants, the use of an African American donor increased the risk of graft loss by 21.5% (P < .001). When African American donors gave kidneys and livers to other African Americans, the relative risks of kidney graft loss were 50.9% higher for a kidney (P < .001) and 36.6% higher for a liver (P < .001) if both the donors and recipients were African American. The relative risk of mortality was 51.3% higher (P < .001) when African American hearts were transplanted into other African Americans. No significant differences existed in terms of the relative risk of cardiac mortality (P < .29) when African American hearts were transplanted into Caucasian recipients. When African American donors provided kidneys and livers to Latinos and Asians, the relative risk of graft loss fell below the rates for Caucasian donors and recipients. However, the differences were not statistically significant. CONCLUSIONS: Our data have identified a pressing need to conduct clinical and prospective research that can isolate the causes of these suboptimal outcomes. This is particularly important since the number of African American organ donors has escalated as a result of recent health outreach and education efforts.

The evolution of volunteerism and professional staff within hospice care in North Carolina.

Although the pursuit of Medicare certification has been one of the most controversial events in hospice history no study has examined its impact using data from a defined population of hospices before, during, and after federal legislation was enacted. This paper revisits the debate over the changing role of volunteers using such a longitudinal data source. Over time, as the patient population grew, aggregate levels of volunteers and professional staff increased. However, the ratios of professional staff and volunteers to patients reveal that regardless of certification status, hospices retained more professional staff per patient and fewer volunteers per patient over time. These data suggest hospices, particularly certified organizations, have transitioned from voluntary organizations to professionally staffed organizations with a strong volunteer component. The most important issue for future research is whether the observed changes have affected the quality of hospice care.

Private health insurance coverage and disability among older Americans.

OBJECTIVES: This study examines the relationship between the lack of private supplemental health insurance coverage and the development of disability among adults aged 65 and older. METHODS: Data are from the baseline and six follow-up waves of the Duke Established Populations for Epidemiologic Studies of the Elderly survey (N = 4,000). Discrete-time hazard models were used to estimate the impact of insurance coverage and other risk factors on the incidence of disability among those unimpaired at baseline. RESULTS: Controlling for education, income, and other potential confounders, the odds of developing disability were 35-49% higher among those without private coverage. Insurance coverage also statistically explained part of the increased risk of disability among low-income persons. DISCUSSION: The results indicate that changes in health insurance coverage as well as in individual behaviors may be needed to reduce disability generally and disability among the socioeconomically disadvantaged, in particular.

Lives through the years revisited.

Williams and Wirths' distinctly sociological study of older adults provides a useful insight into the theory and methods of early interdisciplinary research on social aspects of adulthood and aging in the United States. The Kansas City Study of Adult Life, particularly the concept of disengagement developed there, figured prominently for two decades in theoretical discussions of development in later life. In this sociological presentation, Parsonian action theory is used to develop a framework for assessing the structured interaction of persons and social context, and the autonomy and persistence of life styles which provide a basis for predicting successful aging.

Dynamics of functional impairment in late adulthood.

The inconclusive debate about Fries' theory of "natural death and the compression of morbidity" has diverted attention from two key issues--the modifiability and related dynamics of functional impairment in late adulthood. Evidence is presented from a large (N = 11,000) panel of adults aged initially 58-63 over the period of a decade which documents substantial modification of functional status. Further, patterned changes in functional status are related to the dynamics of income, historically a major determinant of functional status, and independently to educational attainment. The dynamics of functional status, of income, and of their relationship are explored using discrete time hazard models in an event history analysis incorporating time-varying income and functional status indicators. The importance of income and of education as positive, independent predictors of functional status and patterned changes of functional status is confirmed. The implications of this finding for differentiating distal (e.g. education) and proximate (e.g. income) measures of socioeconomic status and for assessing competing theories of social causation and social selection are discussed.

Racial and social correlates of age-related changes in functioning.

Six waves of observations spanning a decade on a panel of 566 Black and 5,196 non-Black survivors were utilized to examine social and racial differences in age-related changes in functioning. An index consisting of three dimensions was used to assess functioning: physical functioning, self-care capacity, and self-rated well-being. Growth curve analysis was used to assess variations in trajectories of functional impairment across Black/non-Black, poor/nonpoor, male/female, and high-school/non-high-school graduate subpanels. Trajectories vary across social groups in the expected manner. However, we note that the trajectories are not linear and that substantial variability exists within both the Black and non-Black subpanels. Moreover, we note that Blacks report poorer functional status than non-Blacks even with income and education controlled. However, age changes do not differ across Black and non-Black subpanels, as predicted by the multiple-jeopardy hypothesis.

The quality and quantity of social support: stroke recovery as psycho-social transition.

The impact of various types and amounts of social support is examined in the context of recovery from first stroke. We conceptualize the rehabilitation process as a psychosocial transition. In a longitudinal design, 44 patients were followed for 6 months following first stroke. Growth-curve analysis (repeated measures MANOVA) was utilized to examine the impact of three types of social support on changes in functional status during recovery. While all three types of support (emotional, instrumental and informational) were shown to be significantly related to recovery of functional capacity, substantial differences were found in the nature of those effects. The impact of social support does not appear during the first month of rehabilitation, indicating the importance of longitudinal designs and longer observation. Patients reporting high level of emotional support showed dramatic improvement despite having the lowest baseline functional status. Instrumental support is most closely related to positive outcomes when provided in moderate amounts. Unlike the other two types, the effect of informational support is mediated by disease severity.

Trajectories of functional impairment in later life.

Functional impairment trajectories in late adulthood over a decade are characterized using the Longitudinal Retirement History Study (LRHS) data set. Non-linear patterns of age-related increase in impairment are documented with longitudinal data. Subsets of panelists from the initial large, nationally representative probability sample of employed males and unmarried employed females (N = 11,000) also exhibit differential non-linear trajectories of impairment by sex, income, and educational attainment. Concurrent analysis of the relationship over a decade among sex, SES, and functional impairment suggests that in health research, both sex and SES are broad proxy variables whose usefulness for understanding health outcomes and for policy analysis would be enhanced by the specification of components.

Social context and personal expenditures for health care: federal policy and the experience of older adults in the 1970s.

The relationship between the intent and the outcome of legislated social policy is discussed. Specifically, this study documents some effects of federal health reimbursement and income policy in the late 1960s and early 1970s on health care behavior and expenditures in the decade 1970-1980. The Longitudinal Retirement History Study (LRHS), containing information on a panel of 6,270 men and unmarried women aged 58 to 63 in 1969, was used to provide information on the personal health expenditures in this decade. Medicare and Medicaid and the indexing of Social Security became operational at the beginning of the study, which permitted the exploration of intended and observed effects of legislation designed to make health care more accessible and affordable for older adults. As policy intended, utilization increased over the decade as indicated by both increases in the number of panelists with health care bills and increases in the size of total bills (constant dollars). Consistent with federal policy to reduce personal costs, out-of-pocket expenditures and the proportion of total bills paid out of pocket decreased. However, the effects of these federal policy initiatives were constrained by reimbursement rules and the social location of users. For instance, even at the end of the 1970s, out-of-pocket health care expenditures across subpopulations persisted. The 1980s and early 1990s have brought increased concern over the cost of health care and renewed concern over access. Data suggest that future proposals aimed at providing universal coverage along with high out-of-pocket costs may not result in equitable programs, and are likely to have a limited impact on constraining health care costs. The LRHS data indicate that utilization increased despite continued high out-of-pocket costs for all except the lower-income groups, who may be limited in their ability to purchase increasingly costly care.

Famine, impoverishment and the creation of a labor reserve in central Tanzania.

An often under-recognized response to drought by members of pastoral and mixed farming communities in Africa is semi-regular migration in search of wage employment. Among the Gogo of the Dodoma and Singida Regions of central Tanzania this strategy has increasingly, since the 1940s, been the response of individuals to a cycle of drought, loss of livestock, and impoverishment. Before World War II hardly any people left Ugogo for wage labor; by 1955 20 per cent of the population was estimated to be absent at any particular time, with the proportion rising sharply during years of drought. Today, local stereotypes depict the Wagogo as beggars and casual laborers throughout Tanzania. The transitional period between 1942 and 1955 was marked by four major famines in which thousands of people died of malnutrition and associated diseases. These famines also marked a dramatic change in the distribution of livestock ownership as wealthy cattle owners no longer used livestock to control the labor of food deficit households and individuals found themselves forced into migrant labor. Colonial policy during and after the war helped precipitate these changes through labor conscription and the demand for labor from the Groundnut Scheme in the Kongwa area of the region.

Resistance to 16 diverse species of herbivorous insects within a population of goldenrod, Solidago altissima: genetic variation and heritability.

Genetic variation in resistance to 16 species of herbivorous insects was studied in 18 clones of Solidago altissima growing in an old field near Ithaca, New York, USA. Resistance to each insect, defined as the abundance of a species attacking a particular host genotype relative to other genotypes, was measured in both the natural stand and in two experimental gardens. The heritability of resistance was estimated by parent-offspring regression and sibcorrelation. The primary result was that clones differed in resistance to 15 of 16 insect species. The resistance of genotypes to these insect species remained relatively constant over the four years of the study. However, for only 10 of these resistances were the heritability estimates significantly different from zero. Thus the common assumption of plant-insect studies - that phenotypic variation in insect abundance is closely correlated with underlying genetic variation - is only conditionally true. There is heritable variation in resistance to many insects, but not all. The insects for which we observed heritable variation in plant resistance represent five different orders and several functional groups, including leaf chewers, phloem and xylem feeders, and gall formers. There was no apparent pattern between the degree of heritability of plant resistance and the destructiveness, feeding method, breadth of host range, or taxonomic group of the insects. The lack of marked heritable variation in resistance to some insects may be the result of (a) reduced variation caused by strong selection during prolonged or repeated insect outbreaks, and (b) genotype-environment interactions that obscure differences among genotypes.