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Open Access Research

If you can't comply with dialysis, how do you expect me to trust you with transplantation? Australian nephrologists' views on indigenous Australians' 'non-compliance' and their suitability for kidney transplantation

Kate Anderson1*, Jeannie Devitt1, Joan Cunningham2, Cilla Preece1, Meg Jardine1 and Alan Cass3

Author Affiliations

1 The George Institute for Global Health, Sydney, Australia

2 Menzies School of Health Research, Charles Darwin University Darwin, Australia, Sydney Medical School, University of Sydney, Sydney, Australia

3 The George Institute for Global Health, Sydney, Australia, Sydney Medical School, University of Sydney, Sydney, Australia

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International Journal for Equity in Health 2012, 11:21  doi:10.1186/1475-9276-11-21

Published: 18 April 2012

Abstract

Introduction

Indigenous Australians suffer markedly higher rates of end-stage kidney disease (ESKD) but are less likely than their non-Indigenous counterparts to receive a transplant. This difference is not fully explained by measurable clinical differences. Previous work suggests that Indigenous Australian patients may be regarded by treating specialists as 'non-compliers', which may negatively impact on referral for a transplant. However, this decision-making is not well understood. The objectives of this study were to investigate: whether Indigenous patients are commonly characterised as 'non-compliers'; how estimations of patient compliance factor into Australian nephrologists' decision-making about transplant referral; and whether this may pose a particular barrier for Indigenous patients accessing transplants.

Methods

Nineteen nephrologists, from eight renal units treating the majority of Indigenous Australian renal patients, were interviewed in 2005-06 as part of a larger study. Thematic analysis was undertaken to investigate how compliance factors in specialists' decision-making, and its implications for Indigenous patients' likelihood of obtaining transplants.

Results

Specialists commonly identified Indigenous patients as both non-compliers and high-risk transplant candidates. Definition and assessment of 'compliance' was neither formal nor systematic. There was uncertainty about the value of compliance status in predicting post-transplant outcomes and the issue of organ scarcity permeated participants' responses. Overall, there was marked variation in how specialists weighed perceptions of compliance and risk in their decision-making.

Conclusion

Reliance on notions of patient 'compliance' in decision-making for transplant referral is likely to result in continuing disadvantage for Indigenous Australian ESKD patients. In the absence of robust evidence on predictors of post-transplant outcomes, referral decision-making processes require attention and debate.

Keywords:
Kidney transplantation; Indigenous peoples; Aboriginal and Torres Strait Islander; Compliance