Assess whether state disability antidiscrimination laws—and provisions for private lawsuits or expedited case review—are associated with reduced disparities in kidney transplant evaluation and receipt for patients with end-stage kidney disease (ESKD) and intellectual and/or developmental disabilities (IDD).
Approach:
Design and data: Cohort study using Medicare claims from 2013 through 2023.
Analysis: Propensity score matching compared patients with and without IDD. Staggered-adoption difference-in-differences models assessed state laws and transplant evaluation and receipt; sensitivity analyses tested alternative cohorts and models.
Key Findings:
Matched cohorts included 12,730 patients with IDD and 49,199 controls.
Compared with controls, patients with IDD had lower rates of transplant evaluation (IRR, 0.78; 95% CI, 0.75-0.81) and transplant receipt (IRR, 0.62; 95% CI, 0.57-0.66).
Passage of an antidiscrimination law was not significantly associated with disparities in evaluation or receipt. Within the IDD group, rates also did not differ significantly by expedited review or private right of action provisions.
Sensitivity analyses produced findings similar to the primary analyses.
Interpretation:
The authors report that the presence of antidiscrimination laws was not associated with more equitable kidney transplant evaluation or receipt rates. They note that legal protections alone may not eliminate disparities and discuss transparency, accountability, and oversight as relevant concerns.
Limitations:
The study lacked measures of transplant appropriateness and social support.
It could not determine whether some patients chose not to pursue evaluation or transplantation.
The authors also cite limitations in cohort identification, data capture, and measurement of transplant access.
Conclusion:
The authors call for advocacy to strengthen antidiscrimination legislation, reduce implicit clinician bias, increase transparency in transplant center decision-making, and ensure holistic eligibility evaluations.
by Brittany N. Hand, J. Madison Hyer, Melica Nikahd, Andrew Gothard, Guy Brock, John Gardner, Lauren Bishop, Lindsay Shea, Lauren Wang, Austin D. Schenk
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