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Brand S, Daga S, Mistry K, Morsy M, Bagul A, Hamer R, Malik S. Sikh and Muslim perspectives on kidney transplantation: phase 1 of the DiGiT project - a qualitative descriptive study. BMJ Open 2023; 13:e059668. [PMID: 38040423 PMCID: PMC10693862 DOI: 10.1136/bmjopen-2021-059668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 10/06/2023] [Indexed: 12/03/2023] Open
Abstract
OBJECTIVES Kidney transplantation offers patients better quality of life and survival compared with dialysis. The risk of end stage renal disease is higher among ethnic minorities and they experience longer wait times on transplant lists. This inequality stems from a high need for kidney transplantation combined with a low rate of deceased donation among ethnic minority groups. This study aimed to explore the perspectives around living donor kidney transplantation of members of the Sikh and Muslim communities with an aim to develop a digital intervention to overcome any barriers. DESIGN A qualitative descriptive study using in person focus groups. SETTING University Teaching Hospital and Transplant Centre. PARTICIPANTS Convenience sampling of participants from the transplant population. Three focus groups were held with 20 participants, all were of South Asian ethnicity belonging to the Sikh and Muslim communities. METHODS Interviews were digitally audio-recorded and transcribed verbatim; transcripts were analysed thematically. RESULTS Four themes were identified: (a) religious issues; (b) lack of knowledge within the community; (c) time; (d) cultural identification with transplantation. CONCLUSIONS Not only is the information given and when it is delivered important, but also the person giving the information is crucial to enhance consideration of live donor kidney transplantation. Information should be in a first language where possible and overtly align to religious considerations. A more integrated approach to transplantation counselling should be adopted which includes healthcare professionals and credible members of the target cultural group. TRIAL REGISTRATION NUMBER NCT04327167.
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Affiliation(s)
- Sarah Brand
- Department of Nephrology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sunil Daga
- Department of Nephrology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kirit Mistry
- South Asian Health Action Charity, Leicester, UK
| | - Mohamed Morsy
- Department of Nephrology and Transplantation, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Atul Bagul
- Department of Nephrology and Transplantation, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Rizwan Hamer
- Department of Renal Transplantation and Nephrology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Shafi Malik
- Department of Nephrology and Transplantation, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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Patzer RE, Zhang R, Buford J, McPherson L, Lee YTH, Urbanski M, Li D, Wilk A, Paul S, Plantinga L, Escoffery C, Pastan SO. The ASCENT Intervention to Improve Access and Reduce Racial Inequalities in Kidney Waitlisting: A Randomized, Effectiveness-Implementation Trial. Clin J Am Soc Nephrol 2023; 18:374-382. [PMID: 36764664 PMCID: PMC10103253 DOI: 10.2215/cjn.0000000000000071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 01/02/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND The US kidney allocation system (KAS) changed in 2014, but dialysis facility staff (including nephrologists, social workers, nurse managers, and facility administrators) had low awareness of how this policy change could affect their patients' access to transplant. We assessed the effectiveness of a multicomponent and multilevel educational and outreach intervention targeting US dialysis facilities with low waitlisting, with a goal of increasing waitlisting and reducing Black versus White racial disparities in waitlisting. METHODS The Allocation System Changes for Equity in Kidney Transplantation (ASCENT) study was a cluster-randomized, pragmatic, multilevel, effectiveness-implementation trial including 655 US dialysis facilities with low waitlisting, randomized to receive either the ASCENT intervention (a performance feedback report, a webinar, and staff and patient educational videos) or an educational brochure. Absolute and relative differences in coprimary outcomes (1-year waitlisting and racial differences in waitlisting) were reported among incident and prevalent patients. RESULTS Among 56,332 prevalent patients, 1-year waitlisting decreased for patients in control facilities (2.72%-2.56%) and remained the same for patients in intervention facilities (2.68%-2.75%). However, the proportion of prevalent Black patients waitlisted in the ASCENT interventions increased from baseline to 1 year (2.52%-2.78%), whereas it remained the same for White patients in the ASCENT intervention facilities (2.66%-2.69%). Among incident patients in ASCENT facilities, 1-year waitlisting increased among Black patients (from 0.87% to 1.07%) but declined among White patients (from 1.54% to 1.27%). Significant racial disparities in waitlisting were observed at baseline, with incident Black patients in ASCENT facilities less likely to waitlist compared with White patients (adjusted odds ratio [aOR], 0.56; 95% confidence interval [CI], 0.35 to 0.92), but 1 year after the intervention, this racial disparity was attenuated (aOR, 0.84; 95% CI, 0.49 to 1.42). CONCLUSIONS The ASCENT intervention may have a small effect on extending the reach of the new KAS policy by attenuating racial disparities in waitlisting among a population of US dialysis facilities with low waitlisting. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER National Institutes of Health ( NCT02879812 ). PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_03_08_CJN09760822.mp3.
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Affiliation(s)
- Rachel E. Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Rebecca Zhang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jade Buford
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Laura McPherson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Yi-Ting Hana Lee
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Megan Urbanski
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Dong Li
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Adam Wilk
- Department of Health Policy and Management, Rollins School of Public Health, Emory University Atlanta, Georgia
| | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Laura Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Cam Escoffery
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Stephen O. Pastan
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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3
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Campbell ZC, Dawson JK, Kirkendall SM, McCaffery KJ, Jansen J, Campbell KL, Lee VW, Webster AC. Interventions for improving health literacy in people with chronic kidney disease. Cochrane Database Syst Rev 2022; 12:CD012026. [PMID: 36472416 PMCID: PMC9724196 DOI: 10.1002/14651858.cd012026.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Low health literacy affects 25% of people with chronic kidney disease (CKD) and is associated with increased morbidity and death. Improving health literacy is a recognised priority, but effective interventions are not clear. OBJECTIVES This review looked the benefits and harms of interventions for improving health literacy in people with CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched MEDLINE (OVID) and EMBASE (OVID) for non-randomised studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies that assessed interventions aimed at improving health literacy in people with CKD. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for eligibility and performed risk of bias analysis. We classified studies as either interventions aimed at improving aspects of health literacy or interventions targeting a population of people with poor health literacy. The interventions were further sub-classified in terms of the type of intervention (educational, self-management training, or educational with self-management training). Results were expressed as mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI) for continuous outcomes and risk ratios (RR) with 95% CI for dichotomous outcomes. MAIN RESULTS We identified 120 studies (21,149 participants) which aimed to improve health literacy. There were 107 RCTs and 13 non-randomised studies. No studies targeted low literacy populations. For the RCTs, selection bias was low or unclear in 94% of studies, performance bias was high in 86% of studies, detection bias was high in 86% of studies reporting subjective outcomes and low in 93% of studies reporting objective outcomes. Attrition and other biases were low or unclear in 86% and 78% of studies, respectively. Compared to usual care, low certainty evidence showed educational interventions may increase kidney-related knowledge (14 RCTs, 2632 participants: SMD 0.99, 95% CI 0.69 to 1.32; I² = 94%). Data for self-care, self-efficacy, quality of life (QoL), death, estimated glomerular filtration rate (eGFR) and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed self-management interventions may improve self-efficacy (5 RCTs, 417 participants: SMD 0.58, 95% CI 0.13 to 1.03; I² = 74%) and QoL physical component score (3 RCTs, 131 participants: MD 4.02, 95% CI 1.09 to 6.94; I² = 0%). There was moderate-certainty evidence that self-management interventions probably did not slow the decline in eGFR after one year (3 RCTs, 855 participants: MD 1.53 mL/min/1.73 m², 95% CI -1.41 to 4.46; I² = 33%). Data for knowledge, self-care behaviour, death and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed educational with self-management interventions may increase knowledge (15 RCTs, 2185 participants: SMD 0.65, 95% CI 0.36 to 0.93; I² = 90%), improve self-care behaviour scores (4 RCTs, 913 participants: SMD 0.91, 95% CI 0.00 to 1.82; I² =97%), self-efficacy (8 RCTs, 687 participants: SMD 0.50, 95% CI 0.10 to 0.89; I² = 82%), improve QoL physical component score (3 RCTs, 2771 participants: MD 2.56, 95% CI 1.73 to 3.38; I² = 0%) and may make little or no difference to slowing the decline of eGFR (4 RCTs, 618 participants: MD 4.28 mL/min/1.73 m², 95% CI -0.03 to 8.85; I² = 43%). Moderate-certainty evidence shows educational with self-management interventions probably decreases the risk of death (any cause) (4 RCTs, 2801 participants: RR 0.73, 95% CI 0.53 to 1.02; I² = 0%). Data for hospitalisation could not be pooled. AUTHORS' CONCLUSIONS Interventions to improve aspects of health literacy are a very broad category, including educational interventions, self-management interventions and educational with self-management interventions. Overall, this type of health literacy intervention is probably beneficial in this cohort however, due to methodological limitations and high heterogeneity in interventions and outcomes, the evidence is of low certainty.
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Affiliation(s)
- Zoe C Campbell
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jessica K Dawson
- Westmead Clinical School, The University of Sydney at Westmead, Westmead, Australia
- Department of Nutrition and Dietetics, St George Hospital, Kogarah, Australia
| | | | - Kirsten J McCaffery
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jesse Jansen
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Family Medicine, School Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands
- Faculty of Health Medicine and Life Sciences (FHML), Maastricht University, Maastricht, Netherlands
| | - Katrina L Campbell
- Centre for Applied Health Economics, Menzies Health Institute Queensland, Griffith University, Nathan, Australia
| | - Vincent Ws Lee
- Westmead Clinical School, The University of Sydney at Westmead, Westmead, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Angela C Webster
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Westmead Applied Research Centre, The University of Sydney at Westmead, Westmead, Australia
- Department of Transplant and Renal Medicine, Westmead Hospital, Westmead, Australia
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Crews DC, Patzer RE, Cervantes L, Knight R, Purnell TS, Powe NR, Edwards DP, Norris KC. Designing Interventions Addressing Structural Racism to Reduce Kidney Health Disparities: A Report from a National Institute of Diabetes and Digestive and Kidney Diseases Workshop. J Am Soc Nephrol 2022; 33:2141-2152. [PMID: 36261301 PMCID: PMC9731627 DOI: 10.1681/asn.2022080890] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Structural racism embodies the many ways in which society fosters racial discrimination through "mutually reinforcing inequitable systems" that limit access to resources and opportunities that can promote health and well being among marginalized communities. To achieve health equity, and kidney health equity more specifically, structural racism must be eliminated. In February 2022, the National Institute of Diabetes and Digestive and Kidney Diseases convened the "Designing Interventions that Address Structural Racism to Reduce Kidney Health Disparities" workshop, which was aimed at describing the mechanisms through which structural racism contributes to health and health care disparities for people along the continuum of kidney disease and identifying actionable opportunities for interventional research focused on dismantling or addressing the effects of structural racism. Participants identified six domains as key targets for interventions and future research: (1) apply an antiracism lens, (2) promote structural interventions, (3) target multiple levels, (4) promote effective community and stakeholder engagement, (5) improve data collection, and (6) advance health equity through new health care models. There is an urgent need for research to develop, implement, and evaluate interventions that address the unjust systems, policies, and laws that generate and perpetuate inequities in kidney health.
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Affiliation(s)
- Deidra C. Crews
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rachel E. Patzer
- Department of Epidemiology, Rollins School of Public Health and School of Medicine, Emory University, Atlanta, Georgia
- Department of Surgery, School of Medicine, Emory University, Atlanta, Georgia
| | - Lilia Cervantes
- Division of Hospital Medicine and General Internal Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - Richard Knight
- American Association of Kidney Patients, Tampa, Florida
- College of Business, Bowie State University, Bowie, Maryland
| | - Tanjala S. Purnell
- Departments of Epidemiology and Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Neil R. Powe
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California
| | | | - Keith C. Norris
- Department of Medicine, University of California Los Angeles, Los Angeles, California
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5
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Aguilar-González A, Lou-Meda R, Chocó-Cedillos A, Moist L. Community engagement in kidney research: Guatemalan experience. BMC Nephrol 2022; 23:282. [PMID: 35962338 PMCID: PMC9373416 DOI: 10.1186/s12882-022-02891-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 07/08/2022] [Indexed: 11/24/2022] Open
Abstract
Background Community engagement is essential for effective research when addressing issues important to both the community and researchers. Despite its effectiveness, there is limited published evidence concerning the evaluation of community engagement in research projects, especially in the area of nephrology. Methods We developed a community engagement program in Guatemala to address the role of hydration in chronic kidney disease of unknown origin, using five key engagement principles: 1. Local relevance and determinants of health. 2. Acknowledgment of the community. 3. Dissemination of findings and knowledge gained to all partners. 4. Usage of community partners’ input. 5. Involvement of a cyclical and iterative process in the pursuit of goals. The effectiveness of community engagement was measured by a structured questionnaire on a 5-point likert scale. This measure determined how well and how often the research team adhered to the five engagement principles. We assessed internal consistency for each set of the engagement items through Omega coefficient. Results Sixty-two community leaders completed the questionnaire. Seventy-five percent were female, with a mean age of 37 years. All 5 engagement principles scored highly on the 5-point likert scale. Every item set corresponding to an engagement principles evaluation had a Omega coefficient > 0.80, indicating a firm internal consistency for all question groups on both qualitative and quantitative scales. Conclusion Engagement of the community in the kidney research provides sustainability of the efforts and facilitates the achievements of the goals. Community leaders and researchers became a team and develop a relationship in which commitment and empowerment facilitated the participation in all aspects of the research process. This initiative could be a useful tool for researchers, especially in low-middle income countries, to start research in a community, achieve objectives in a viable form, and open opportunities to further studies. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02891-8.
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Affiliation(s)
- Angie Aguilar-González
- Foundation for Children With Kidney Disease -FUNDANIER-, 6 avenida 9-18 zona 10, torre 1, Oficina 804, Edificio Sixtino 2, Guatemala, 01010, Guatemala.
| | - Randall Lou-Meda
- Foundation for Children With Kidney Disease -FUNDANIER-, 6 avenida 9-18 zona 10, torre 1, Oficina 804, Edificio Sixtino 2, Guatemala, 01010, Guatemala
| | - André Chocó-Cedillos
- Foundation for Children With Kidney Disease -FUNDANIER-, 6 avenida 9-18 zona 10, torre 1, Oficina 804, Edificio Sixtino 2, Guatemala, 01010, Guatemala
| | - Louise Moist
- Division of Nephrology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Canada.,Kidney Clinical Research Unit, London Health Sciences Centre, London, Canada
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Hamid M, Rogers E, Chawla G, Gill J, Macanovic S, Mucsi I. Pretransplant Patient Education in Solid-organ Transplant: A Narrative Review. Transplantation 2022; 106:722-733. [PMID: 34260472 DOI: 10.1097/tp.0000000000003893] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Education for pretransplant, solid-organ recipient candidates aims to improve knowledge and understanding about the transplant process, outcomes, and potential complications to support informed, shared decision-making to reduce fears and anxieties about transplant, inform expectations, and facilitate adjustment to posttransplant life. In this review, we summarize novel pretransplant initiatives and approaches to educate solid-organ transplant recipient candidates. First, we review approaches that may be common to all solid-organ transplants, then we summarize interventions specific to kidney, liver, lung, and heart transplant. We describe evidence that emphasizes the need for multidisciplinary approaches to transplant education. We also summarize initiatives that consider online (eHealth) and mobile (mHealth) solutions. Finally, we highlight education initiatives that support racialized or otherwise marginalized communities to improve equitable access to solid-organ transplant. A considerable amount of work has been done in solid-organ transplant since the early 2000s with promising results. However, many studies on education for pretransplant recipient candidates involve relatively small samples and nonrandomized designs and focus on short-term surrogate outcomes. Overall, many of these studies have a high risk of bias. Frequently, interventions assessed are not well characterized or they are combined with administrative and data-driven initiatives into multifaceted interventions, which makes it difficult to assess the impact of the education component on outcomes. In the future, well-designed studies rigorously assessing well-defined surrogate and clinical outcomes will be needed to evaluate the impact of many promising initiatives.
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Affiliation(s)
- Marzan Hamid
- Multi-Organ Transplant Program and Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
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Gender Disparities in Kidney Transplantation Referral Vary by Age and Race – A Multi-Regional Cohort Study in the Southeast US. Kidney Int Rep 2022; 7:1248-1257. [PMID: 35694555 PMCID: PMC9174037 DOI: 10.1016/j.ekir.2022.03.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 03/23/2022] [Accepted: 03/28/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Methods Results Conclusion
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Adler RR, Smith RN, Fowler KJ, Gates J, Jefferson NM, Adler JT, Patzer RE. Community Based Participatory Research (CBPR): An Underutilized Approach to Address Surgical Disparities. Ann Surg 2022; 275:496-499. [PMID: 34913903 DOI: 10.1097/sla.0000000000005329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Disparities are well-documented across the continuum of surgical care. Counteracting such disparities requires new multidisciplinary approaches that utilize the expertise of affected individuals, such as community-based participatory research (CBPR). CBPR is an approach to research that is anchored in equitable, sustainable community-academic partnerships, and has been shown to improve intervention implementation and outcomes. In this article, community stakeholders and researchers outline the principles and benefits of CBPR, examples of CBPR in trauma and transplant, and future directions for CBPR within surgery.
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Affiliation(s)
- Rachel R Adler
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Randi N Smith
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | | | | | | | - Joel T Adler
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, TX
| | - Rachel E Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
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A scoping review of inequities in access to organ transplant in the United States. Int J Equity Health 2022; 21:22. [PMID: 35151327 PMCID: PMC8841123 DOI: 10.1186/s12939-021-01616-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 12/24/2021] [Indexed: 02/06/2023] Open
Abstract
Background Organ transplant is the preferred treatment for end-stage organ disease, yet the majority of patients with end-stage organ disease are never placed on the transplant waiting list. Limited access to the transplant waiting list combined with the scarcity of the organ pool result in over 100,000 deaths annually in the United States. Patients face unique barriers to referral and acceptance for organ transplant based on social determinants of health, and patients from disenfranchised groups suffer from disproportionately lower rates of transplantation. Our objective was to review the literature describing disparities in access to organ transplantation based on social determinants of health to integrate the existing knowledge and guide future research. Methods We conducted a scoping review of the literature reporting disparities in access to heart, lung, liver, pancreas and kidney transplantation based on social determinants of health (race, income, education, geography, insurance status, health literacy and engagement). Included studies were categorized based on steps along the transplant care continuum: referral for transplant, transplant evaluation and selection, living donor identification/evaluation, and waitlist outcomes. Results Our search generated 16,643 studies, of which 227 were included in our final review. Of these, 34 focused on disparities in referral for transplantation among patients with chronic organ disease, 82 on transplant selection processes, 50 on living donors, and 61 on waitlist management. In total, 15 studies involved the thoracic organs (heart, lung), 209 involved the abdominal organs (kidney, liver, pancreas), and three involved multiple organs. Racial and ethnic minorities, women, and patients in lower socioeconomic status groups were less likely to be referred, evaluated, and added to the waiting list for organ transplant. The quality of the data describing these disparities across the transplant literature was variable and overwhelmingly focused on kidney transplant. Conclusions This review contextualizes the quality of the data, identifies seminal work by organ, and reports gaps in the literature where future research on disparities in organ transplantation should focus. Future work should investigate the association of social determinants of health with access to the organ transplant waiting list, with a focus on prospective analyses that assess interventions to improve health equity. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-021-01616-x.
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Community Engagement to Improve Equity in Kidney Transplantation from the Ground Up: the Southeastern Kidney Transplant Coalition. CURRENT TRANSPLANTATION REPORTS 2021; 8:324-332. [DOI: 10.1007/s40472-021-00346-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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11
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Browne T, McPherson L, Retzloff S, Darius A, Wilk AS, Cruz A, Wright S, Pastan SO, Gander JC, Berlin AA, Patzer RE. Improving Access to Kidney Transplantation: Perspectives From Dialysis and Transplant Staff in the Southeastern United States. Kidney Med 2021; 3:799-807.e1. [PMID: 34693259 PMCID: PMC8515088 DOI: 10.1016/j.xkme.2021.04.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Rationale & Objective There are many barriers to meeting the goal of increasing kidney transplants in the United States. It is important to understand dialysis and transplant center providers’ existing practices and identified barriers to increasing the number of dialysis patients who are evaluated for and get wait-listed for a transplant. Study Design Cross-sectional survey of dialysis unit and transplant center staff in End Stage Renal Disease Network 6 (Georgia, North Carolina, South Carolina). Setting & Participants Ninety-one transplant staff from all 9 transplant centers in the region and 421 dialysis staff from 421 facilities responded to the survey. Predictors N/A Outcome Provider perceptions of barriers faced by patients in the kidney transplant evaluation process and suggestions for improving care. Analytical Approach Mixed methods. Descriptive analyses of responses to multiple-choice questions and qualitative analysis of open-ended survey responses. Results The top 5 barriers to kidney transplantation as reported by transplant staff were transportation (63.7%), low health literacy (50.5%), lack of understanding about the transplant process (37.4%), distance to transplant center (29.7%), and low socioeconomic status (28.6%). When asked how dialysis units can help patients complete the evaluation process, the most common responses from transplant center staff were educating patients about transplant (54%), helping patients through steps in the process (35%), and better communication with transplant centers (15%). When dialysis unit staff were asked what could be done to help the facility improve its transplant wait-list rate, the most common responses were educational materials for patients and staff (55%), better communication with transplant centers (12%), and transportation and financial assistance (9%). Limitations Survey responses are from 1 end stage renal disease network. Conclusions Dialysis units, transplant centers, and ESRD networks can work together to help patients address key barriers to transplantation to improve the country’s transplantation rate.
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Affiliation(s)
- Teri Browne
- College of Social Work, University of South Carolina, Columbia, SC
| | - Laura McPherson
- Department of Epidemiology, Rollins School of Public Health, Atlanta, GA.,Health Services Research Center, Department of Medicine and Department of Surgery, Emory University School of Medicine, Atlanta, GA.,Department of Surgery, School of Medicine, Atlanta, GA
| | - Samantha Retzloff
- Health Services Research Center, Department of Medicine and Department of Surgery, Emory University School of Medicine, Atlanta, GA.,Department of Surgery, School of Medicine, Atlanta, GA
| | - Amandha Darius
- Department of Epidemiology, Rollins School of Public Health, Atlanta, GA.,Health Services Research Center, Department of Medicine and Department of Surgery, Emory University School of Medicine, Atlanta, GA.,Department of Surgery, School of Medicine, Atlanta, GA
| | - Adam S Wilk
- Department of Health Policy and Management, Rollins School of Public Health, Atlanta, GA
| | | | | | - Stephen O Pastan
- Renal Division, Department of Medicine, School of Medicine, Emory University School of Medicine, Atlanta, GA.,Health Services Research Center, Department of Medicine and Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Jennifer C Gander
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA
| | | | - Rachel E Patzer
- Department of Epidemiology, Rollins School of Public Health, Atlanta, GA.,Health Services Research Center, Department of Medicine and Department of Surgery, Emory University School of Medicine, Atlanta, GA.,Department of Surgery, School of Medicine, Atlanta, GA
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Non-medical barriers in access to early steps of kidney transplantation in the United States - A scoping review. Transplant Rev (Orlando) 2021; 35:100654. [PMID: 34597944 DOI: 10.1016/j.trre.2021.100654] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/16/2021] [Accepted: 09/17/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND In the United States (US), barriers in access to later steps in the kidney transplantation process (i.e. waitlisting) have been well documented. Barriers in access to earlier steps (i.e. referral and evaluation) are less well described due to the lack of national surveillance data. In this review, we summarize the available literature on non-medical barriers in access to kidney transplant referral and evaluation. METHODS Following PRISMA guidelines, we conducted a scoping review of the literature through June 3, 2021. We included all studies (quantitative and qualitative) reporting on barriers to kidney transplant referral and evaluation in the US published from 1990 onwards in English and among adult end-stage kidney disease (ESKD) patients (PROSPERO registration number: CRD42014015027). We narratively synthesized results across studies. RESULTS We retrieved information from 33 studies published from 1990 to 2021 (reporting data between 1990 and 2018). Most studies (n = 28, 85%) described barriers among patient populations, three (9%) among provider populations, and two (6%) included both patients and providers. Key barriers were identified across multiple levels and included patient- (e.g. demographic, socioeconomic, sociocultural, and knowledge), provider- (e.g. miscommunication, staff availability, provider perceptions and attitudes), and system- (e.g. geography, distance to care, healthcare logistics) level factors. CONCLUSIONS A multi-pronged approach (e.g. targeted and systemwide interventions, and policy change) implemented at multiple levels of the healthcare system will be necessary to reduce identified barriers in access to early kidney transplant steps. Collection of national surveillance data on these early kidney transplant steps is also needed to enhance our understanding of barriers to referral and evaluation.
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Lowe D, Ryan R, Schonfeld L, Merner B, Walsh L, Graham-Wisener L, Hill S. Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation. Cochrane Database Syst Rev 2021; 9:CD013373. [PMID: 34523117 PMCID: PMC8440158 DOI: 10.1002/14651858.cd013373.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Health services have traditionally been developed to focus on specific diseases or medical specialties. Involving consumers as partners in planning, delivering and evaluating health services may lead to services that are person-centred and so better able to meet the needs of and provide care for individuals. Globally, governments recommend consumer involvement in healthcare decision-making at the systems level, as a strategy for promoting person-centred health services. However, the effects of this 'working in partnership' approach to healthcare decision-making are unclear. Working in partnership is defined here as collaborative relationships between at least one consumer and health provider, meeting jointly and regularly in formal group formats, to equally contribute to and collaborate on health service-related decision-making in real time. In this review, the terms 'consumer' and 'health provider' refer to partnership participants, and 'health service user' and 'health service provider' refer to trial participants. This review of effects of partnership interventions was undertaken concurrently with a Cochrane Qualitative Evidence Synthesis (QES) entitled Consumers and health providers working in partnership for the promotion of person-centred health services: a co-produced qualitative evidence synthesis. OBJECTIVES To assess the effects of consumers and health providers working in partnership, as an intervention to promote person-centred health services. SEARCH METHODS We searched the CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL databases from 2000 to April 2019; PROQUEST Dissertations and Theses Global from 2016 to April 2019; and grey literature and online trial registries from 2000 until September 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs of 'working in partnership' interventions meeting these three criteria: both consumer and provider participants meet; they meet jointly and regularly in formal group formats; and they make actual decisions that relate to the person-centredness of health service(s). DATA COLLECTION AND ANALYSIS Two review authors independently screened most titles and abstracts. One review author screened a subset of titles and abstracts (i.e. those identified through clinical trials registries searches, those classified by the Cochrane RCT Classifier as unlikely to be an RCT, and those identified through other sources). Two review authors independently screened all full texts of potentially eligible articles for inclusion. In case of disagreement, they consulted a third review author to reach consensus. One review author extracted data and assessed risk of bias for all included studies and a second review author independently cross-checked all data and assessments. Any discrepancies were resolved by discussion, or by consulting a third review author to reach consensus. Meta-analysis was not possible due to the small number of included trials and their heterogeneity; we synthesised results descriptively by comparison and outcome. We reported the following outcomes in GRADE 'Summary of findings' tables: health service alterations; the degree to which changed service reflects health service user priorities; health service users' ratings of health service performance; health service users' health service utilisation patterns; resources associated with the decision-making process; resources associated with implementing decisions; and adverse events. MAIN RESULTS We included five trials (one RCT and four cluster-RCTs), with 16,257 health service users and more than 469 health service providers as trial participants. For two trials, the aims of the partnerships were to directly improve the person-centredness of health services (via health service planning, and discharge co-ordination). In the remaining trials, the aims were indirect (training first-year medical doctors on patient safety) or broader in focus (which could include person-centredness of health services that targeted the public/community, households or health service delivery to improve maternal and neonatal mortality). Three trials were conducted in high income-countries, one was in a middle-income country and one was in a low-income country. Two studies evaluated working in partnership interventions, compared to usual practice without partnership (Comparison 1); and three studies evaluated working in partnership as part of a multi-component intervention, compared to the same intervention without partnership (Comparison 2). No studies evaluated one form of working in partnership compared to another (Comparison 3). The effects of consumers and health providers working in partnership compared to usual practice without partnership are uncertain: only one of the two studies that assessed this comparison measured health service alteration outcomes, and data were not usable, as only intervention group data were reported. Additionally, none of the included studies evaluating this comparison measured the other primary or secondary outcomes we sought for the 'Summary of findings' table. We are also unsure about the effects of consumers and health providers working in partnership as part of a multi-component intervention compared to the same intervention without partnership. Very low-certainty evidence indicated there may be little or no difference on health service alterations or health service user health service performance ratings (two studies); or on health service user health service utilisation patterns and adverse events (one study each). No studies evaluating this comparison reported the degree to which health service alterations reflect health service user priorities, or resource use. Overall, our confidence in the findings about the effects of working in partnership interventions was very low due to indirectness, imprecision and publication bias, and serious concerns about risk of selection bias; performance bias, detection bias and reporting bias in most studies. AUTHORS' CONCLUSIONS The effects of consumers and providers working in partnership as an intervention, or as part of a multi-component intervention, are uncertain, due to a lack of high-quality evidence and/or due to a lack of studies. Further well-designed RCTs with a clear focus on assessing outcomes directly related to partnerships for patient-centred health services are needed in this area, which may also benefit from mixed-methods and qualitative research to build the evidence base.
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Affiliation(s)
- Dianne Lowe
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Rebecca Ryan
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Lina Schonfeld
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Bronwen Merner
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Louisa Walsh
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | | | - Sophie Hill
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
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14
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Boulware LE, Sudan DL, Strigo TS, Ephraim PL, Davenport CA, Pendergast JF, Pounds I, Riley JA, Falkovic M, Alkon A, Hill-Briggs F, Cabacungan AN, Barrett TM, Mohottige D, McElroy L, Diamantidis CJ, Ellis MJ. Transplant social worker and donor financial assistance to increase living donor kidney transplants among African Americans: The TALKS Study, a randomized comparative effectiveness trial. Am J Transplant 2021; 21:2175-2187. [PMID: 33210831 DOI: 10.1111/ajt.16403] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/14/2020] [Accepted: 10/31/2020] [Indexed: 01/25/2023]
Abstract
Lack of donors hinders living donor kidney transplantation (LDKT) for African Americans. We studied the effectiveness of a transplant social worker intervention (TALK SWI) alone or paired with living donor financial assistance to activate African Americans' potential living kidney donors. African Americans (N = 300) on the transplant waiting list were randomly assigned to usual care; TALK SWI; or TALK SWI plus Living Donor Financial Assistance. We quantified differences in live kidney donor activation (composite rate of live donor inquiries, completed new live donor evaluations, or live kidney donation) after 12 months. Participants' mean age was 52 years, 56% were male, and 43% had annual household income less than $40,000. Most previously pursued LDKT. Participants were highly satisfied with TALK social workers, but they rarely utilized Financial Assistance. After 12 months, few (n = 39, 13%) participants had a new donor activation event (35 [12%] new donor inquiries; 17 [6%] new donor evaluations; 4 [1%] LDKT). There were no group differences in donor activation events (subdistribution hazard ratio [95% CI]: 1.09 [0.51-2.30] for TALK SWI and 0.92 [0.42-2.02] for TALK SWI plus Financial Assistance compared to Usual Care, p = 91). Alternative interventions to increase LDKT for African Americans on the waiting list may be needed. Trial registration: ClinicalTrials.gov (NCT02369354).
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Affiliation(s)
- L Ebony Boulware
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Debra L Sudan
- Division of Abdominal Transplant, Duke Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Tara S Strigo
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Patti L Ephraim
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Baltimore, MD, USA
| | - Clemontina A Davenport
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Jane F Pendergast
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Iris Pounds
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jennie A Riley
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Margaret Falkovic
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Aviel Alkon
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Felicia Hill-Briggs
- Welch Center for Prevention, Epidemiology and Clinical Research, Baltimore, MD, USA.,Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ashley N Cabacungan
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Tyler M Barrett
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Dinushika Mohottige
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Lisa McElroy
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Division of Abdominal Transplant, Duke Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Clarissa J Diamantidis
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Matthew J Ellis
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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15
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Yohanna S, Naylor KL, Mucsi I, McKenzie S, Belenko D, Blake PG, Coghlan C, Dixon SN, Elliott L, Getchell L, Ki V, Nesrallah G, Patzer RE, Presseau J, Reich M, Sontrop JM, Treleaven D, Waterman AD, Zaltzman J, Garg AX. A Quality Improvement Intervention to Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD) in Patients With Chronic Kidney Disease: Clinical Research Protocol of a Cluster-Randomized Clinical Trial. Can J Kidney Health Dis 2021; 8:2054358121997266. [PMID: 33948191 PMCID: PMC8054216 DOI: 10.1177/2054358121997266] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Indexed: 12/31/2022] Open
Abstract
Background: Many patients with kidney failure will live longer and healthier lives if
they receive a kidney transplant rather than dialysis. However, multiple
barriers prevent patients from accessing this treatment option. Objective: To determine if a quality improvement intervention provided in chronic kidney
disease (CKD) programs (vs. usual care) enables more patients with no
recorded contraindications to kidney transplant to complete more steps
toward receiving a kidney transplant. Design: This protocol describes a pragmatic 2-arm, parallel-group, open-label,
registry-based, cluster-randomized clinical trial—the Enhance Access to
Kidney Transplantation and Living Kidney Donation (EnAKT LKD) trial. Setting: All 26 CKD programs in Ontario, Canada, with a trial start date of November
1, 2017. The original end date of March 31, 2021 (3.4 years) has been
extended to December 31, 2021 (4.1 years) due to the COVID-19 pandemic. Participants: During the trial, the 26 CKD programs are expected to care for more than 10
000 adult patients with CKD (including patients approaching the need for
dialysis and patients receiving dialysis) with no recorded contraindications
to a kidney transplant. Intervention: Programs were randomly allocated to provide a quality improvement
intervention or usual care. The intervention has 4 main components: (1)
local quality improvement teams and administrative support; (2) tailored
education and resources for staff, patients, and living kidney donor
candidates; (3) support from kidney transplant recipients and living kidney
donors; and (4) program-level performance reports and oversight by program
leaders. Primary Outcome: The primary outcome is the number of key steps completed toward receiving a
kidney transplant analyzed at the cluster level (CKD program). The following
4 unique steps per patient will be counted: (1) patient referred to a
transplant center for evaluation, (2) at least one living kidney donor
candidate contacts a transplant center for an intended recipient and
completes a health history questionnaire to begin their evaluation, (3)
patient added to the deceased donor transplant wait list, and (4) patient
receives a kidney transplant from a living or deceased donor. Planned Primary Analysis: Study data will be obtained from Ontario’s linked administrative healthcare
databases. An intent-to-treat analysis will be conducted comparing the
primary outcome between randomized groups using a 2-stage approach. First
stage: residuals are obtained from fitting a regression model to
individual-level variables ignoring intervention and clustering effects.
Second stage: residuals from the first stage are aggregated at the cluster
level as the outcome. Limitations: It may not be possible to isolate independent effects of each intervention
component, the usual care group could adopt intervention components leading
to contamination bias, and the relatively small number of clusters could
mean the 2 arms are not balanced on all baseline prognostic factors. Conclusions: The EnAKT LKD trial will provide high-quality evidence on whether a
multi-component quality improvement intervention helps patients complete
more steps toward receiving a kidney transplant. Trial registration: Clinicaltrials.gov; identifier: NCT03329521.
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Affiliation(s)
| | - Kyla L Naylor
- ICES, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Istvan Mucsi
- Division of Nephrology, University of Toronto, ON, Canada
| | | | - Dmitri Belenko
- Division of Nephrology, University of Toronto, ON, Canada
| | - Peter G Blake
- Division of Nephrology, Western University, London, ON, Canada.,Ontario Renal Network, Ontario Health, Toronto, Canada
| | | | - Stephanie N Dixon
- ICES, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Lori Elliott
- Ontario Renal Network, Ontario Health, Toronto, Canada
| | - Leah Getchell
- Division of Nephrology, London Health Sciences Centre, ON, Canada
| | - Vincent Ki
- Ontario Renal Network, Ontario Health, Toronto, Canada.,Trillium Health Partners, Mississauga, ON, Canada
| | - Gihad Nesrallah
- Ontario Renal Network, Ontario Health, Toronto, Canada.,Humber River Regional Hospital, Toronto, ON, Canada
| | - Rachel E Patzer
- Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Health Research Institute, ON, Canada
| | - Marian Reich
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease, Patient Council, Vancouver, BC, Canada
| | - Jessica M Sontrop
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Division of Nephrology, London Health Sciences Centre, ON, Canada
| | - Darin Treleaven
- Division of Nephrology, McMaster University, Hamilton, ON, Canada.,Trillium Gift of Life Network, Toronto, ON, Canada
| | - Amy D Waterman
- Division of Nephrology, University of California, Los Angeles, USA
| | - Jeffrey Zaltzman
- Trillium Gift of Life Network, Toronto, ON, Canada.,Division of Nephrology, St. Michael's Hospital, Toronto, ON, Canada
| | - Amit X Garg
- ICES, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Division of Nephrology, Western University, London, ON, Canada.,Ontario Renal Network, Ontario Health, Toronto, Canada
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16
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Paul S, Melanson T, Mohan S, Ross-Driscoll K, McPherson L, Lynch R, Lo D, Pastan SO, Patzer RE. Kidney transplant program waitlisting rate as a metric to assess transplant access. Am J Transplant 2021; 21:314-321. [PMID: 32808730 PMCID: PMC7980228 DOI: 10.1111/ajt.16277] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 01/25/2023]
Abstract
Kidney transplant program performance in the United States is commonly measured by posttransplant outcomes. Inclusion of pretransplant measures could provide a more comprehensive assessment of transplant program performance and necessary information for patient decision-making. In this study, we propose a new metric, the waitlisting rate, defined as the ratio of patients who are waitlisted in a center relative to the person-years referred for evaluation to a program. Furthermore, we standardize the waitlisting rate relative to the state average in Georgia, North Carolina, and South Carolina. The new metric was used as a proof-of-concept to assess transplant-program access compared to the existing transplant rate metric. The study cohorts were defined by linking 2017 United States Renal Data System (USRDS) data with transplant-program referral data from the Southeastern United States between January 1, 2012 and December 31, 2016. Waitlisting rate varied across the 9 Southeastern transplant programs, ranging from 10 to 22 events per 100 patient-years, whereas the program-specific waitlisting rate ratio ranged between 0.76 and 1.33. Program-specific waitlisting rate ratio was uncorrelated with the transplant rate ratio (r = -.15, 95% CI, -0.83 to 0.57). Findings warrant collection of national data on early transplant steps, such as referral, for a more comprehensive assessment of transplant program performance and pretransplant access.
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Affiliation(s)
- Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Taylor Melanson
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia
| | - Sumit Mohan
- Department of Medicine, Vagelos College of Physicians & Surgeons, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Katherine Ross-Driscoll
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Laura McPherson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Raymond Lynch
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia
| | - Denise Lo
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia
| | - Stephen O. Pastan
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E. Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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17
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A Video Intervention to Increase Organ Donor Registration at the Department of Motorized Vehicles. Transplantation 2020; 104:788-794. [PMID: 31356581 DOI: 10.1097/tp.0000000000002880] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The goal of this study was to increase organ donor registrations at the Department of Motorized Vehicles (DMV) via utilization of a sustainable, low-cost, African American-centric organ donation educational video. Results from previous studies provided a framework to generate a 10-minute video that featured registered organ donors, deceased donor families, and transplant recipients. METHODS The video was presented via an interrupted time series design (repeating on 2 mo, off 2 mo) on televisions placed in 6 regional DMVs. During the 12-month study, 162 387 patrons visited the DMVs. RESULTS Increases in organ donor registration were consistently observed in each DMV while the video was on compared with off (mean = +2.3% [range +1.98% to +3.35%]; P < 0.0001). Multivariable analysis demonstrated that females (odds ratio [OR], 1.29; 95% confidence interval [CI], 1.26-1.31), younger age (OR, 0.982/y; 95% CI, 0.982-0.983), and the video intervention (OR, 1.09; 95% CI, 1.07-1.12) were significantly associated with increased registration; while compared with Caucasian race, African American race was not (OR, 0.22; 95% CI, 0.22-0.23). There was no video-dependent effect on registration between Caucasians and African Americans (P = 0.62). Exit interviews demonstrated only 16% of patrons could identify the key message in the video (becoming a registered organ donor). CONCLUSIONS An educational video promoting organ donation resulted in increased organ donor registration at the DMV. The intervention was equally effective in African Americans and Caucasians. Future efforts should focus upon target-specific messaging and patron consumption of the educational video.
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18
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Longer Distance From Dialysis Facility to Transplant Center Is Associated With Lower Access to Kidney Transplantation. Transplant Direct 2020; 6:e602. [PMID: 33134482 PMCID: PMC7591118 DOI: 10.1097/txd.0000000000001048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 06/26/2020] [Indexed: 11/26/2022] Open
Abstract
Rates of kidney transplantation vary substantially across dialysis facilities in the United States. Whether distance between the dialysis facility and transplant center associates with variations in transplantation rates has not been examined.
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19
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Magua W, Basu M, Pastan SO, Kim JJ, Smith K, Gander J, Mohan S, Escoffery C, Plantinga LC, Melanson T, Garber MD, Patzer RE. Effect of the ASCENT Intervention to Increase Knowledge of Kidney Allocation Policy Changes Among Dialysis Providers. Kidney Int Rep 2020; 5:1422-1431. [PMID: 32954067 PMCID: PMC7486341 DOI: 10.1016/j.ekir.2020.06.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/29/2020] [Accepted: 06/23/2020] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The Allocation System Changes for Equity in Kidney Transplantation (ASCENT) trial was a cluster-randomized pragmatic, effectiveness-implementation study designed to test whether a multicomponent educational intervention targeting leadership, clinic staff, and patients in dialysis facilities improved knowledge and awareness of the 2014 Kidney Allocation System (KAS) change. METHODS Participants included 690 dialysis facility medical directors, nephrologists, social workers, and other staff within 655 US dialysis facilities, with 51% (n = 334) in the intervention group and 49% (n = 321) in the control group. Intervention activities included a webinar targeting medical directors and facility staff, an approximately 10-minute educational video targeting dialysis staff, an approximately 10-minute educational video targeting patients, and a facility-specific audit and feedback report of transplant performance. The control group received a standard United Network for Organ Sharing brochure. Provider knowledge was a secondary outcome of the ASCENT trial and the primary outcome of this study; knowledge was assessed as a cumulative score on a 5-point Likert scale (higher score = greater knowledge). Intention-to-treat analysis was used. RESULTS At baseline, nonintervention providers had a higher mean knowledge score (mean ± SD, 2.45 ± 1.43) than intervention providers (mean ± SD, 2.31 ± 1.46). After 3 months, the average knowledge score was slightly higher in the intervention (mean ± SD, 3.14 ± 1.28) versus nonintervention providers (mean ± SD, 3.07 ± 1.24), and the estimated mean difference in knowledge scores between the groups at follow-up minus the mean difference at baseline was 0.25 (95% confidence interval [CI], 0.11-0.48; P = 0.039). The effect size (0.41) was low to moderate. CONCLUSION Dialysis facility provider education could help extend the impact of a national policy change in organ allocation.
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Affiliation(s)
- Wairimu Magua
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mohua Basu
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Stephen O. Pastan
- Department of Medicine, Renal Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Joyce J. Kim
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kayla Smith
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jennifer Gander
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Cam Escoffery
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Laura C. Plantinga
- Department of Medicine, Renal Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Taylor Melanson
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael D. Garber
- Department of Epidemiology, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rachel E. Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Medicine, Renal Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia, USA
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20
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Patzer RE, McPherson L, Wang Z, Plantinga LC, Paul S, Ellis M, DuBay DA, Wolf J, Reeves-Daniel A, Jones H, Zayas C, Mulloy L, Pastan SO. Dialysis facility referral and start of evaluation for kidney transplantation among patients treated with dialysis in the Southeastern United States. Am J Transplant 2020; 20:2113-2125. [PMID: 31981441 DOI: 10.1111/ajt.15791] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/02/2020] [Accepted: 01/19/2020] [Indexed: 01/25/2023]
Abstract
Variability in transplant access exists, but barriers to referral and evaluation are underexplored due to lack of national surveillance data. We examined referral for kidney transplantation evaluation and start of the evaluation among 34 857 incident, adult (18-79 years) end-stage kidney disease patients from 690 dialysis facilities in the United States Renal Data System from January 1, 2012 through August 31, 2016, followed through February 2018 and linked data to referral and evaluation data from nine transplant centers in Georgia, North Carolina, and South Carolina. Multivariable-adjusted competing risk analysis examined each outcome. The median within-facility cumulative percentage of patients referred for kidney transplantation within 1 year of dialysis at the 690 dialysis facilities in Network 6 was 33.7% (interquartile range [IQR]: 25.3%-43.1%). Only 48.3% of referred patients started the transplant evaluation within 6 months of referral. In multivariable analyses, factors associated with referral vs evaluation start among those referred at any time differed. For example, black, non-Hispanic patients had a higher rate of referral (hazard ratio [HR]: 1.22; 95% confidence interval [CI]: 1.18-1.27), but lower evaluation start among those referred (HR: 0.93; 95% CI: 0.88-0.98), vs white non-Hispanic patients. Barriers to transplant varied by step, and national surveillance data should be collected on early transplant steps to improve transplant access.
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Affiliation(s)
- Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Emory Transplant Center, Atlanta, Georgia, USA
| | - Laura McPherson
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Zhensheng Wang
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Laura C Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Matthew Ellis
- Departments of Medicine and Surgery, Duke University, Durham, North Carolina, USA
| | - Derek A DuBay
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Joshua Wolf
- Piedmont Transplant Institute, Piedmont Healthcare, Atlanta, Georgia, USA
| | | | - Heather Jones
- Vidant Medical Center, Greenville, North Carolina, USA
| | - Carlos Zayas
- Division of Nephrology, Department of Medicine, Augusta University, Augusta, Georgia, USA
| | - Laura Mulloy
- Division of Nephrology, Department of Medicine, Augusta University, Augusta, Georgia, USA
| | - Stephen O Pastan
- Emory Transplant Center, Atlanta, Georgia, USA.,Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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21
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McPherson LJ, Barry V, Yackley J, Gander JC, Pastan SO, Plantinga LC, Paul S, Patzer RE. Distance to Kidney Transplant Center and Access to Early Steps in the Kidney Transplantation Process in the Southeastern United States. Clin J Am Soc Nephrol 2020; 15:539-549. [PMID: 32209583 PMCID: PMC7133136 DOI: 10.2215/cjn.08530719] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 12/23/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Access to kidney transplantation requires a referral to a transplant center for medical evaluation. Prior research suggests that the distance that a person must travel to reach a center might be a barrier to referral. We examined whether a shorter distance from patients' residence to a transplant center increased the likelihood of referral and initiating the transplant evaluation once referred. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Adults who began treatment for ESKD at any Georgia, North Carolina, or South Carolina dialysis facility from 1/1/2012 to 12/31/2015 were identified from the US Renal Data System. Referral (within 1 year of dialysis initiation) and evaluation initiation (within 6 months of referral) data were collected from all nine transplant centers located in that region. Distance was categorized as <15, 15-30, 31-60, 61-90, and >90 miles from the center of a patient's residential zip code to the nearest center. We used multilevel, multivariable-adjusted logistic regression to quantify the association between distance with referral and evaluation initiation. RESULTS Among 27,250 adult patients on incident dialysis, 9582 (35%) were referred. Among those referred, 58% initiated evaluation. Although patients who lived farther from a center were less likely to be referred, distance was not statistically significantly related to transplant referral: adjusted odds ratios of 1.08 (95% confidence interval, 0.96 to 1.22), 1.07 (95% confidence interval, 0.95 to 1.22), 0.96 (95% confidence interval, 0.84 to 1.10), and 0.87 (95% confidence interval, 0.74 to 1.03) for 15-30, 31-60, 61-90, and >90 miles, respectively, compared with <15 miles (P trend =0.05). There was no statistically significant association of distance and evaluation initiation among referred patients: adjusted odds ratios of 1.14 (95% confidence interval, 0.97 to 1.33), 1.12 (95% confidence interval, 0.94 to 1.35), 1.04 (95% confidence interval, 0.87 to 1.25), and 0.89 (95% confidence interval, 0.72 to 1.11) for 15-30, 31-60, 61-90, and >90 miles, respectively, compared with <15 miles (P trend =0.70). CONCLUSIONS Distance from residence to transplant center among patients undergoing long-term dialysis in the southeastern United States was not associated with increased likelihood of referral and initiating transplant center evaluation.
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Affiliation(s)
- Laura J McPherson
- Departments of Surgery and.,Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Jane Yackley
- Tennessee Department of Health, Nashville, Tennessee
| | - Jennifer C Gander
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia
| | | | - Laura C Plantinga
- Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia; and
| | - Rachel E Patzer
- Departments of Surgery and .,Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia
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22
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Patzer RE, Pastan SO. Policies to promote timely referral for kidney transplantation. Semin Dial 2020; 33:58-67. [PMID: 31957930 DOI: 10.1111/sdi.12860] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/14/2019] [Indexed: 02/06/2023]
Abstract
There are numerous patient, provider, and health system barriers to accessing kidney transplantation. Patient barriers such as sociocultural and clinical characteristics and provider factors such as provider knowledge and awareness of transplantation play important roles in facilitating transplant. Health system factors like misaligned incentives and quality metrics for dialysis facilities and transplant centers also influence transplant access. While numerous studies have documented the impact of these barriers on wait-listing and transplant, few studies have examined referral from a dialysis facility to a transplant center and start of the transplant evaluation process. While the Centers for Medicare and Medicaid Services (CMS) require that dialysis facilities educate patients about transplant, there are no guidelines for the content and objectives for this education. In addition, policies to require timely referral for transplantation have been considered by CMS but are difficult to implement without national data on referral. Federal policies should be amended to mandate transplant center submission of referral data-while decreasing the unfunded mandate to collect other unusable data currently collected as part of regulatory monitoring of transplant centers-to promote timely access to transplant, increased transplant rates, and to better understand the multilevel barriers and facilitators to transplant referral.
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Affiliation(s)
- Rachel E Patzer
- Department of Medicine, Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA.,Department of Surgery, Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA.,Emory Transplant Center, Atlanta, GA, USA.,Department of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
| | - Stephen O Pastan
- Department of Medicine, Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA.,Department of Surgery, Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA.,Emory Transplant Center, Atlanta, GA, USA.,Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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23
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Stevenson JK, Campbell ZC, Webster AC, Chow CK, Tong A, Craig JC, Campbell KL, Lee VWS. eHealth interventions for people with chronic kidney disease. Cochrane Database Syst Rev 2019; 8:CD012379. [PMID: 31425608 PMCID: PMC6699665 DOI: 10.1002/14651858.cd012379.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is associated with high morbidity and death, which increases as CKD progresses to end-stage kidney disease (ESKD). There has been increasing interest in developing innovative, effective and cost-efficient methods to engage with patient populations and improve health behaviours and outcomes. Worldwide there has been a tremendous increase in the use of technologies, with increasing interest in using eHealth interventions to improve patient access to relevant health information, enhance the quality of healthcare and encourage the adoption of healthy behaviours. OBJECTIVES This review aims to evaluate the benefits and harms of using eHealth interventions to change health behaviours in people with CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 14 January 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs using an eHealth intervention to promote behaviour change in people with CKD were included. There were no restrictions on outcomes, language or publication type. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial eligibility, extracted data and assessed the risk of bias. The certainty of the evidence was assessed using GRADE. MAIN RESULTS We included 43 studies with 6617 participants that evaluated the impact of an eHealth intervention in people with CKD. Included studies were heterogeneous in terms of eHealth modalities employed, type of intervention, CKD population studied and outcomes assessed. The majority of studies (39 studies) were conducted in an adult population, with 16 studies (37%) conducted in those on dialysis, 11 studies (26%) in the pre-dialysis population, 15 studies (35%) in transplant recipients and 1 studies (2%) in transplant candidates We identified six different eHealth modalities including: Telehealth; mobile or tablet application; text or email messages; electronic monitors; internet/websites; and video or DVD. Three studies used a combination of eHealth interventions. Interventions were categorised into six types: educational; reminder systems; self-monitoring; behavioural counselling; clinical decision-aid; and mixed intervention types. We identified 98 outcomes, which were categorised into nine domains: blood pressure (9 studies); biochemical parameters (6 studies); clinical end-points (16 studies); dietary intake (3 studies); quality of life (9 studies); medication adherence (10 studies); behaviour (7 studies); physical activity (1 study); and cost-effectiveness (7 studies).Only three outcomes could be meta-analysed as there was substantial heterogeneity with respect to study population and eHealth modalities utilised. There was found to be a reduction in interdialytic weight gain of 0.13kg (4 studies, 335 participants: MD -0.13, 95% CI -0.28 to 0.01; I2 = 0%) and a reduction in dietary sodium intake of 197 mg/day (2 studies, 181 participants: MD -197, 95% CI -540.7 to 146.8; I2 = 0%). Both dietary sodium and fluid management outcomes were graded as being of low evidence due to high or unclear risk of bias and indirectness (interdialytic weight gain) and high or unclear risk of bias and imprecision (dietary sodium intake). Three studies reported death (2799 participants, 146 events), with 45 deaths/1000 cases compared to standard care of 61 deaths/1000 cases (RR 0.74, CI 0.53 to 1.03; P = 0.08). We are uncertain whether using eHealth interventions, in addition to usual care, impact on the number of deaths as the certainty of this evidence was graded as low due to high or unclear risk of bias, indirectness and imprecision. AUTHORS' CONCLUSIONS eHealth interventions may improve the management of dietary sodium intake and fluid management. However, overall these data suggest that current evidence for the use of eHealth interventions in the CKD population is of low quality, with uncertain effects due to methodological limitations and heterogeneity of eHealth modalities and intervention types. Our review has highlighted the need for robust, high quality research that reports a core (minimum) data set to enable meaningful evaluation of the literature.
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Affiliation(s)
- Jessica K Stevenson
- The University of SydneyWestmead Clinical SchoolCentre for Kidney ResearchCnr Darcy Rd and Hawksbury RdWestmead, SydneyNSWAustralia2145
| | - Zoe C Campbell
- The University of SydneyDepartment of MedicineSydneyNSWAustralia2006
| | - Angela C Webster
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
| | - Clara K Chow
- The George Institute for Global HealthCardiovascular DepartmentLevel 10, 83‐117 Missenden RoadCamperdownNSWAustralia2050
| | - Allison Tong
- The Children's Hospital at WestmeadCentre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | - Katrina L Campbell
- Bond UniversityFaculty of Health Science and Medicine2 Promenthean WayRobinaQueenslandAustralia4226
| | - Vincent WS Lee
- Westmead & Blacktown HospitalsDepartment of Renal MedicineDarcy RdWestmeadNSWAustralia2145
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Patzer RE, McPherson L, Redmond N, DuBay D, Zayas C, Hartmann E, Mulloy L, Perryman J, Pastan S, Arriola KJ. A Culturally Sensitive Web-based Intervention to Improve Living Donor Kidney Transplant Among African Americans. Kidney Int Rep 2019; 4:1285-1295. [PMID: 31517147 PMCID: PMC6737208 DOI: 10.1016/j.ekir.2019.05.771] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 05/03/2019] [Accepted: 05/20/2019] [Indexed: 01/23/2023] Open
Abstract
Introduction There are pervasive racial disparities in access to living donor kidney transplantation, which for most patients with end-stage renal disease (ESRD) represents the optimal treatment. We previously developed a theory-driven, culturally sensitive intervention for African American (AA) patients with kidney disease called Living ACTS (About Choices in Transplantation and Sharing) as a DVD and booklet, and found this intervention was effective in increasing living donor transplant knowledge. However, it is unknown whether modifying this intervention for a Web-based environment is effective at increasing access to living donor transplantation. Methods We describe the Web-based Living ACTS study, a multicenter, randomized controlled study designed to test the effectiveness of a revised Living ACTS intervention in 4 transplant centers in the southeastern United States. The intervention consists of a Web site with 5 modules: Introduction, Benefits and Risks, The Kidney Transplant Process, Identifying a Potential Kidney Donor, and ACT Now (which encourages communication with friends and family about transplantation). Results This study will enroll approximately 800 patients from the 4 transplant centers. The primary outcome is the percentage of patients with at least 1 inquiry from a potential living donor among patients who receive Living ACTS as compared with those who receive a control Web site. Conclusion The results from this study are expected to demonstrate the effectiveness of an intervention designed to increase access to living donor transplantation among AA individuals. If successful, the Web-based intervention could be disseminated across the >250 transplant centers in the United States to improve equity in living donor kidney transplantation.
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Affiliation(s)
- Rachel E Patzer
- Health Services Research Center, Department of Medicine and Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health of Emory University, Atlanta, Georgia, USA
- Emory Transplant Center, Atlanta, Georgia, USA
| | - Laura McPherson
- Health Services Research Center, Department of Medicine and Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Derek DuBay
- Department of Transplant Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Carlos Zayas
- Renal and Pancreas Transplant Program, Augusta University, Augusta, Georgia, USA
| | - Erica Hartmann
- Piedmont Transplant Institute, Piedmont Hospital, Atlanta, Georgia, USA
| | - Laura Mulloy
- Department of Nephrology, Hypertension, and Transplant Medicine, Augusta University, Augusta, Georgia, USA
| | | | - Stephen Pastan
- Emory Transplant Center, Atlanta, Georgia, USA
- Department of Medicine, Division of Renal Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kimberly Jacob Arriola
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health of Emory University, Atlanta, Georgia, USA
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25
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Johnson M, Lacy N, Wilson J, Oakley K, Gianaris K, Perkins JA, Blanck JF, Purnell TS. Overcoming Disparities in Living Donor Kidney Transplantation in the USA: the Promise of Academic and Community Stakeholder Partnerships. CURRENT TRANSPLANTATION REPORTS 2019. [DOI: 10.1007/s40472-019-00244-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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26
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Mercado-Martínez FJ, Madrigal-Vargas P, Sánchez-Pimienta CE. [Social participation and health: a collaborative experience on chronic kidney disease.]. SALUD PUBLICA DE MEXICO 2018; 60:559-565. [PMID: 30550117 DOI: 10.21149/9054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 06/28/2018] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To identify challenges derived from renal insufficiency, as well as potential solutions and an agenda for action. MATERIALS AND METHODS y adopting a collaborative research approach, diverse stakeholders -sick people, family members, advocacy groups, health professionals, and academics- participated in two gatherings in the context of the World Kidney Day in Guadalajara, Mexico and created an agenda for action. Data was gathered through group discussions. RESULTS Two main issues are faced by kidney sick people and their family members: the first one related with health services and, second, the lack of economic resources to pay for renal treatment. The agenda for action included rallying on public squares, installing day of the dead altars, video making, and publishing a book. CONCLUSIONS Participation of diverse stakeholders is a valuable option to face challenges derived from renal insufficiency.
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Affiliation(s)
- Francisco J Mercado-Martínez
- Departamento de Salud Pública, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara. Guadalajara, México
| | - Paulina Madrigal-Vargas
- Departamento de Salud Pública, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara. Guadalajara, México
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27
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Gander JC, Zhang X, Plantinga L, Paul S, Basu M, Pastan SO, Gibney E, Hartmann E, Mulloy L, Zayas C, Patzer RE. Racial disparities in preemptive referral for kidney transplantation in Georgia. Clin Transplant 2018; 32:e13380. [PMID: 30099781 DOI: 10.1111/ctr.13380] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 07/30/2018] [Accepted: 08/06/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Racial disparities persist in access to kidney transplantation. Racial differences in preemptive referral, or referral prior to dialysis start, may explain this discrepancy. METHODS Patient-level data on kidney transplant referrals (2005-2012) from all Georgia transplant centers were linked to the United States Renal Data System to examine racial disparities in preemptive referral, waitlisting, and living donor transplant. Adjusted logistic regression and Cox proportional hazard models determined the associations between race (African American vs white) and preemptive referral, and placement on the waitlist and receipt of a living donor kidney, respectively. RESULTS Among 7752 adults referred for transplant evaluation, 20.38% (n = 1580) were preemptively referred. The odds of African Americans being preemptively referred for transplant evaluation were 37% (OR = 0.63; [95% CI: 0.55 0.71]) lower than white patients. Among preemptively referred patients, there was no racial difference (African Americans compared to white patients. HR = 0.96; [95% CI: 0.88, 1.04]) in waitlisting. However, African Americans were 70% less likely than white patients to receive a living donor transplant (HR = 0.30; [95% CI: 0.21, 0.42]). CONCLUSION Racial disparities in transplant receipt may be partially explained by disparities in preemptive referral. Interventions to reduce racial disparities in kidney transplant access may need to be targeted earlier in the disease process.
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Affiliation(s)
- Jennifer C Gander
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia
| | - Xingyu Zhang
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Laura Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Mohua Basu
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Stephen O Pastan
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Eric Gibney
- Piedmont Healthcare, Piedmont Transplant Institute, Atlanta, Georgia
| | - Erica Hartmann
- Piedmont Healthcare, Piedmont Transplant Institute, Atlanta, Georgia
| | - Laura Mulloy
- Division of Nephrology, Department of Medicine, Augusta University, Augusta, Georgia
| | - Carlos Zayas
- Division of Nephrology, Department of Medicine, Augusta University, Augusta, Georgia
| | - Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Patzer RE, McPherson L, Basu M, Mohan S, Wolf M, Chiles M, Russell A, Gander JC, Friedewald JJ, Ladner D, Larsen CP, Pearson T, Pastan S. Effect of the iChoose Kidney decision aid in improving knowledge about treatment options among transplant candidates: A randomized controlled trial. Am J Transplant 2018; 18:1954-1965. [PMID: 29446209 PMCID: PMC6510396 DOI: 10.1111/ajt.14693] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 01/05/2018] [Accepted: 02/04/2018] [Indexed: 01/25/2023]
Abstract
We previously developed a mobile- and web-based decision aid (iChoose Kidney) that displays individualized risk estimates of survival and mortality, for the treatment modalities of dialysis versus kidney transplantation. We examined the effect of iChoose Kidney on change in transplant knowledge and access to transplant in a randomized controlled trial among patients presenting for evaluation in three transplant centers. A total of 470 patients were randomized to standard transplantation education (control) or standard education plus iChoose Kidney (intervention). Change in transplant knowledge (primary outcome) among intervention versus control patients was assessed using nine items in pre- and postevaluation surveys. Access to transplant (secondary outcome) was defined as a composite of waitlisting, living donor inquiries, or transplantation. Among 443 patients (n = 226 intervention; n = 216 control), the mean knowledge scores were 5.1 ± 2.1 pre- and 5.8 ± 1.9 postevaluation. Change in knowledge was greater among intervention (1.1 ± 2.0) versus control (0.4 ± 1.8) patients (P < .0001). Access to transplantation was similar among intervention (n = 168; 74.3%) versus control patients (n = 153; 70.5%; P = .37). The iChoose Kidney decision aid improved patient knowledge at evaluation, but did not impact transplant access. Future studies should examine whether combining iChoose Kidney with other interventions can increase transplantation. (Clinicaltrials.gov NCT02235571).
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Affiliation(s)
- Rachel E. Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Laura McPherson
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Mohua Basu
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Michael Wolf
- Northwestern University Comprehensive Transplant Center, Chicago, IL, USA
| | - Mariana Chiles
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Allison Russell
- Northwestern University Comprehensive Transplant Center, Chicago, IL, USA
| | - Jennifer C. Gander
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - John J. Friedewald
- Northwestern University Comprehensive Transplant Center, Chicago, IL, USA
| | - Daniela Ladner
- Northwestern University Comprehensive Transplant Center, Chicago, IL, USA
| | - Christian P. Larsen
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Thomas Pearson
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Stephen Pastan
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Brett KE, Ritchie LJ, Ertel E, Bennett A, Knoll GA. Quality Metrics in Solid Organ Transplantation: A Systematic Review. Transplantation 2018; 102:e308-e330. [PMID: 29557915 PMCID: PMC7228649 DOI: 10.1097/tp.0000000000002149] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 12/20/2017] [Accepted: 01/14/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND The best approach for determining whether a transplant program is delivering high-quality care is unknown. This review aims to identify and characterize quality metrics in solid organ transplantation. METHODS Medline, Embase, and Cochrane Central Register of Controlled Trials were searched from inception until February 1, 2017. Relevant full text reports and conference abstracts that examined quality metrics in organ transplantation were included. Two reviewers independently extracted study characteristics and quality metrics from 52 full text reports and 24 abstracts. PROSPERO registration: CRD42016035353. RESULTS Three hundred seventeen quality metrics were identified and condensed into 114 unique indicators with sufficient detail to be measured in practice; however, many lacked details on development and selection, were poorly defined, or had inconsistent definitions. The process for selecting quality indicators was described in only 5 publications and patient involvement was noted in only 1. Twenty-four reports used the indicators in clinical care, including 12 quality improvement studies. Only 14 quality metrics were assessed against patient and graft survivals. CONCLUSIONS More than 300 quality metrics have been reported in transplantation but many lacked details on development and selection, were poorly defined, or had inconsistent definitions. Measures have focused on safety and effectiveness with very few addressing other quality domains, such as equity and patient-centeredness. Future research will need to focus on transparent and objective metric development with proper testing, evaluation, and implementation in practice. Patients will need to be involved to ensure that transplantation quality metrics measure what is important to them.
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Affiliation(s)
- Kendra E Brett
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Lindsay J Ritchie
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Emily Ertel
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alexandria Bennett
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Greg A Knoll
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Nephrology, Kidney Research Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Paul S, Plantinga LC, Pastan SO, Gander JC, Mohan S, Patzer RE. Standardized Transplantation Referral Ratio to Assess Performance of Transplant Referral among Dialysis Facilities. Clin J Am Soc Nephrol 2018; 13:282-289. [PMID: 29371341 PMCID: PMC5967424 DOI: 10.2215/cjn.04690417] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 10/24/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES For patients with ESRD, referral from a dialysis facility to a transplant center for evaluation is an important step toward kidney transplantation. However, a standardized measure for assessing clinical performance of dialysis facilities transplant access is lacking. We describe methodology for a new dialysis facility measure: the Standardized Transplantation Referral Ratio. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Transplant referral data from 8308 patients with incident ESRD within 249 dialysis facilities in the United States state of Georgia were linked with US Renal Data System data from January of 2008 to December of 2011, with follow-up through December of 2012. Facility-level expected referrals were computed from a two-stage Cox proportional hazards model after patient case mix risk adjustment including demographics and comorbidities. The Standardized Transplantation Referral Ratio (95% confidence interval) was calculated as a ratio of observed to expected referrals. Measure validity and reliability were assessed. RESULTS Over 2008-2011, facility Standardized Transplantation Referral Ratios in Georgia ranged from 0 to 4.87 (mean =1.16, SD=0.76). Most (77%) facilities had observed referrals as expected, whereas 11% and 12% had Standardized Transplantation Referral Ratios significantly greater than and less than expected, respectively. Age, race, sex, and comorbid conditions were significantly associated with the likelihood of referral, and they were included in risk adjustment for Standardized Transplantation Referral Ratio calculations. The Standardized Transplantation Referral Ratios were positively associated with evaluation, waitlisting, and transplantation (r=0.46, 0.35, and 0.20, respectively; P<0.01). On average, approximately 33% of the variability in Standardized Transplantation Referral Ratios was attributed to between-facility variation, and 67% of the variability in Standardized Transplantation Referral Ratios was attributed to within-facility variation. CONCLUSIONS The majority of observed variation in dialysis facility referral performance was due to characteristics within a dialysis facility rather than patient factors included in risk adjustment models. Our study shows a method for computing a facility-level standardized measure for transplant referral on the basis of a pilot sample of Georgia dialysis facilities that could be used to monitor transplant referral performance of dialysis facilities.
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Affiliation(s)
- Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Laura C. Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Renal Division, Department of Medicine and
| | - Stephen O. Pastan
- Renal Division, Department of Medicine and
- Emory Transplant Center, Atlanta, Georgia
| | - Jennifer C. Gander
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Sumit Mohan
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; and
- Department of Epidemiology, Mailman School of Public Health, New York, New York
| | - Rachel E. Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Emory Transplant Center, Atlanta, Georgia
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McElfish PA, Ayers BL, Purvis RS, Long CR, Sinclair K, Esquivel M, Steelman SC. Best practices for community-engaged participatory research with Pacific Islander communities in the USA and USAPI: protocol for a scoping review. BMJ Open 2018; 8:e019653. [PMID: 29371285 PMCID: PMC5786128 DOI: 10.1136/bmjopen-2017-019653] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 12/01/2017] [Accepted: 12/08/2017] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Community-based participatory research is a partnership approach to research that seeks to equally involve community members, organisational representatives and academic partners throughout the research process in a coequal and mutually beneficial partnership. To date, no published article has synthesised the best practices for community-based participatory research practices with Pacific Islanders. METHODS AND ANALYSIS The reviewers will examine studies' titles, abstracts and full text, comparing eligibility to address discrepancies. For each eligible study, data extraction will be executed by two reviewers and one confirmation coder, comparing extracted data to address any discrepancies. Eligible data will be synthesised and reported in a narrative review assessing coverage and gaps in existing literature related to community-based participatory research with Pacific Islanders. DISCUSSION AND DISSEMINATION The purpose of this review is to identify best practices used when conducting community-based participatory research with Pacific Islanders; it will also extrapolate where the gaps are in the existing literature. This will be the first scoping review on community-based participatory research with Pacific Islanders. To facilitate dissemination, the results of this scoping review will be submitted for publication to a peer-reviewed journal, presented at conferences and shared with community-based participatory research stakeholders.
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Affiliation(s)
- Pearl Anna McElfish
- Office of Community Health and Research, University of Arkansas for Medical Sciences, Fayetteville, Arkansas, USA
- College of Medicine, University of Arkansas for Medical Sciences, Fayetteville, Arkansas, USA
| | - Britni L Ayers
- Office of Community Health and Research, University of Arkansas for Medical Sciences, Fayetteville, Arkansas, USA
| | - Rachel S Purvis
- Office of Community Health and Research, University of Arkansas for Medical Sciences, Fayetteville, Arkansas, USA
| | - Christopher R Long
- Office of Community Health and Research, University of Arkansas for Medical Sciences, Fayetteville, Arkansas, USA
- College of Medicine, University of Arkansas for Medical Sciences, Fayetteville, Arkansas, USA
| | - Ka'imi Sinclair
- Initiative for Research and Education to Advance Community Health (IREACH), College of Nursing, Washington State University, Seattle, Washington, USA
| | - Monica Esquivel
- Department of Human Nutrition, Food and Animal Sciences, University of Hawai'i at Mānoa, Honolulu, Hawaii, USA
| | - Susan C Steelman
- Division of Academic Affairs, University of Arkansas for Medical Sciences Library, Little Rock, Arkansas, USA
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Hamoda RE, Gander JC, McPherson LJ, Arriola KJ, Cobb L, Pastan SO, Plantinga L, Browne T, Hartmann E, Mulloy L, Zayas C, Krisher J, Patzer RE. Process evaluation of the RaDIANT community study: a dialysis facility-level intervention to increase referral for kidney transplantation. BMC Nephrol 2018; 19:13. [PMID: 29334900 PMCID: PMC5769303 DOI: 10.1186/s12882-017-0807-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 12/21/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The Reducing Disparities in Access to kidNey Transplantation Community Study (RaDIANT) was an End-Stage Renal Disease (ESRD) Network 6-developed, dialysis facility-level randomized trial testing the effectiveness of a 1-year multicomponent education and quality improvement intervention in increasing referral for kidney transplant evaluation among selected Georgia dialysis facilities. METHODS To assess implementation of the RaDIANT intervention, we conducted a process evaluation at the conclusion of the intervention period (January-December 2014). We administered a 20-item survey to the staff involved with transplant education in 67 dialysis facilities randomized to participate in intervention activities. Survey items assessed facility participation in the intervention (fidelity and reach), helpfulness and willingness to continue intervention activities (sustainability), suggestions for improving intervention components (sustainability), and factors that may have influenced participation and study outcomes (context). We defined high fidelity to the intervention as completing 11 or more activities, and high participation in an activity as having at least 75% participation across intervention facilities. RESULTS Staff from 65 of the 67 dialysis facilities completed the questionnaire, and more than half (50.8%) reported high adherence (fidelity) to RaDIANT intervention requirements. Nearly two-thirds (63.1%) of facilities reported that RaDIANT intervention activities were helpful or very helpful, with 90.8% of facilities willing to continue at least one intervention component beyond the study period. Intervention components with high participation emphasized staff and patient-level education, including in-service staff orientations, patient and family education programs, and patient educational materials. Suggested improvements for intervention activities emphasized addressing financial barriers to transplantation, with financial education materials perceived as most helpful among RaDIANT educational materials. Variation in facility-level fidelity of the RADIANT intervention did not significantly influence the mean difference in proportion of patients referred pre- (2013) and post-intervention (2014). CONCLUSIONS We found high fidelity to the RaDIANT multicomponent intervention at the majority of intervention facilities, with sustainability of select intervention components at intervention facilities and feasibility for dissemination across ESRD Networks. Future modification of the intervention should emphasize financial education regarding kidney transplantation and amend intervention components that facilities perceive as time-intensive or non-sustainable. TRIAL REGISTRATION Clinicaltrials.gov number NCT02092727 . Registered 13 Mar 2014 (retrospectively registered).
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Affiliation(s)
- Reem E Hamoda
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 1629 Pierce Dr. NE, 30322, Atlanta, Georgia, USA.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Jennifer C Gander
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 1629 Pierce Dr. NE, 30322, Atlanta, Georgia, USA
| | - Laura J McPherson
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 1629 Pierce Dr. NE, 30322, Atlanta, Georgia, USA
| | - Kimberly J Arriola
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Loren Cobb
- Department of Biology, Spelman College, Atlanta, Georgia, USA
| | - Stephen O Pastan
- Department of Medicine, Division of Renal Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Laura Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.,Department of Medicine, Division of Renal Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Teri Browne
- College of Social Work, University of South Carolina, Columbia, South Carolina, USA
| | | | - Laura Mulloy
- Division of Nephrology, Hypertension, and Transplant, Augusta University, Augusta, Georgia, USA
| | - Carlos Zayas
- Division of Nephrology, Hypertension, and Transplant, Augusta University, Augusta, Georgia, USA
| | - Jenna Krisher
- Southeastern Kidney Transplant Coalition, End Stage Renal Disease Network 6, Raleigh, North Carolina, USA
| | - Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 1629 Pierce Dr. NE, 30322, Atlanta, Georgia, USA. .,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.
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Lipford KJ, McPherson L, Hamoda R, Browne T, Gander JC, Pastan SO, Patzer RE. Dialysis facility staff perceptions of racial, gender, and age disparities in access to renal transplantation. BMC Nephrol 2018; 19:5. [PMID: 29316901 PMCID: PMC5761143 DOI: 10.1186/s12882-017-0800-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 12/18/2017] [Indexed: 11/30/2022] Open
Abstract
Background Racial/ethnic, gender, and age disparities in access to renal transplantation among end-stage renal disease (ESRD) patients have been well documented, but few studies have explored health care staff attitudes towards these inequalities. Staff perceptions can influence patient care and outcomes, and identifying staff perceptions on disparities could aid in the development of potential interventions to address these health inequities. The objective of this study was to investigate dialysis staff (n = 509), primarily social workers and nurse managers, perceptions of renal transplant disparities in the Southeastern United States. Methods This is a mixed methods study that uses both deductive and inductive qualitative analysis of a dialysis staff survey conducted in 2012 using three open-ended questions that asked staff to discuss their perceptions of factors that may contribute to transplant disparities among African American, female, and elderly patients. Results Study results suggested that the majority of staff (n = 255, 28%) perceived patients’ low socioeconomic status as the primary theme related to why renal transplant disparities exist between African Americans and non-Hispanic whites. Staff cited patient perception of old age as a primary contributor (n = 188, 23%) to the disparity between young and elderly patients. The dialysis staff responses on gender transplant disparities suggested that staff were unaware of differences due to limited experience and observation (n = 76, 14.7%) of gender disparities. Conclusions These findings suggest that dialysis facilities should educate staff on existing renal transplantation disparities, particularly gender disparities, and collaboratively work with transplant facilities to develop strategies to actively address modifiable patient barriers for transplant.
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Affiliation(s)
- Kristie J Lipford
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 1639 Pierce Dr. NE, Atlanta, GA, 30322, USA.
| | - Laura McPherson
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 1639 Pierce Dr. NE, Atlanta, GA, 30322, USA
| | - Reem Hamoda
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 1639 Pierce Dr. NE, Atlanta, GA, 30322, USA
| | - Teri Browne
- College of Social Work, University of South Carolina, Columbia, SC, USA
| | - Jennifer C Gander
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 1639 Pierce Dr. NE, Atlanta, GA, 30322, USA
| | - Stephen O Pastan
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 1639 Pierce Dr. NE, Atlanta, GA, 30322, USA
| | - Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 1639 Pierce Dr. NE, Atlanta, GA, 30322, USA
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Gross O, de Andrade V, Gagnayre R. [Community-based research in therapeutic patient education: practices and contributions. A literature review]. SANTE PUBLIQUE 2017; 29:551-562. [PMID: 29034670 DOI: 10.3917/spub.174.0551] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Community-based research (CBR) in health involves both researchers and people concerned by the results of the research. It aims to empower populations, using their exposure to the phenomenon being studied as a starting point. The use of CBR in the field of therapeutic patient education (TPE) is of interest, as the two share such characteristics as the desire to foster self-reliance and participation and a culture of interdisciplinarity. AIM To characterize CBR in the therapeutic patient education field. METHODS A literature search on PUBMED using the keywords ?community-based (participatory) research?, ?patient education?, ?self-care? and ?self-management? retrieved 121 articles. The analysis looked at the type of research, the characteristics of both the populations involved and the co-researchers, the collaborative actions (analysed using a grid from the literature), and the difficulties in implementing these actions. RESULTS Thirty-one studies were included. Ten consisted of methodological studies, which tended to show the added value of collaborating with users in implementing TPE programmes compared to standard methods. The remaining 21 studies described the co-design and/or co-execution of new educational programmes. We identified 5 collaborative actions that involved a preparatory phase of the research, and 17 collaborative actions that involved the prioritization, conduct, and analysis of the research and dissemination of the results. Preventive measures are needed for potential methodological, organizational, ethical, and emotional difficulties. DISCUSSION The 22 identified actions need to be confirmed by other studies. The analysis grid could ultimately become a tool for guiding researchers for their researches within the CBR framework.
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Harding K, Mersha TB, Webb FA, Vassalotti JA, Nicholas SB. Current State and Future Trends to Optimize the Care of African Americans with End-Stage Renal Disease. Am J Nephrol 2017; 46:156-164. [PMID: 28787724 DOI: 10.1159/000479479] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Chronic kidney disease is a progressive disease, which terminates in end-stage renal diseases (ESRD) that requires either dialysis or kidney transplantation for the patient to survive. There is an alarming trend in the disparities of ESRD in African Americans (AAs). Currently, AAs represent more than 30% of incident ESRD cases, yet they constitute 15% of the overall US population. Despite the reductions in mortality, increases in access to patient-centered home dialysis and preemptive kidney transplantation for the overall US ESRD population over the last decade, disparities in the care of AAs with ESRD remain largely unaffected. SUMMARY This review discusses patient-, community-, and practitioner-related factors that contribute to disparities in ESRD care for AAs. In particular, the review addresses issues related to end-of-life support, the importance of Apolipoprotein-1 gene variants, and the advent of pharmacogenomics toward achieving precision care. The need for accessible clinical intelligence for the ESRD population is discussed. Several interventions and a call to action to address the disparities are presented. Key Messages: Significant disparities in ESRD care exist for AAs. Strategies to enhance patient engagement, education, accountable partnerships, and clinical intelligence may reduce these disparities.
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Ethnic Background Is a Potential Barrier to Living Donor Kidney Transplantation in Canada: A Single-Center Retrospective Cohort Study. Transplantation 2017; 101:e142-e151. [PMID: 28207634 DOI: 10.1097/tp.0000000000001658] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND We examined if African or Asian ethnicity was associated with lower access to kidney transplantation (KT) in a Canadian setting. METHODS Patients referred for KT to the Toronto General Hospital from January 1, 2003, to December 31, 2012, who completed social work assessment, were included (n = 1769). The association between ethnicity and the time from referral to completion of KT evaluation or receipt of a KT were examined using Cox proportional hazards models. RESULTS About 54% of the sample was white, 13% African, 11% East Asian, and 11% South Asian; 7% had "other" (n = 121) ethnic background. African Canadians (hazard ratio [HR], 0.75; 95% CI: 0.62-0.92]) and patients with "other" ethnicity (HR, 0.71; 95% CI, 0.55-0.92) were less likely to complete the KT evaluation compared with white Canadians, and this association remained statistically significant in multivariable adjusted models. Access to KT was significantly reduced for all ethnic groups assessed compared with white Canadians, and this was primarily driven by differences in access to living donor KT. The adjusted HRs for living donor KT were 0.35 (95% CI, 0.24-0.51), 0.27 (95% CI, 0.17-0.41), 0.43 (95% CI, 0.30-0.61), and 0.34 (95% CI, 0.20-0.56) for African, East or South Asian Canadians and for patients with "other" ethnic background, respectively. CONCLUSIONS Similar to other jurisdictions, nonwhite patients face barriers to accessing KT in Canada. This inequity is very substantial for living donor KT. Further research is needed to identify if these inequities are due to potentially modifiable barriers.
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Talamantes E, Norris KC, Mangione CM, Moreno G, Waterman AD, Peipert JD, Bunnapradist S, Huang E. Linguistic Isolation and Access to the Active Kidney Transplant Waiting List in the United States. Clin J Am Soc Nephrol 2017; 12:483-492. [PMID: 28183854 PMCID: PMC5338711 DOI: 10.2215/cjn.07150716] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 11/15/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND OBJECTIVES Waitlist inactivity is a barrier to transplantation, because inactive candidates cannot receive deceased donor organ offers. We hypothesized that temporarily inactive kidney transplant candidates living in linguistically isolated communities would be less likely to achieve active waitlist status. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We merged Organ Procurement and Transplantation Network/United Network for Organ Sharing data with five-digit zip code socioeconomic data from the 2000 US Census. The cumulative incidence of conversion to active waitlist status, death, and delisting before conversion among 84,783 temporarily inactive adult kidney candidates from 2004 to 2012 was determined using competing risks methods. Competing risks regression was performed to characterize the association between linguistic isolation, incomplete transplantation evaluation, and conversion to active status. A household was determined to be linguistically isolated if all members ≥14 years old speak a non-English language and also, speak English less than very well. RESULTS A total of 59,147 candidates (70% of the study population) achieved active status over the study period of 9.8 years. Median follow-up was 110 days (interquartile range, 42-276 days) for activated patients and 815 days (interquartile range, 361-1244 days) for candidates not activated. The cumulative incidence of activation over the study period was 74%, the cumulative incidence of death before conversion was 10%, and the cumulative incidence of delisting was 13%. After adjusting for other relevant covariates, living in a zip code with higher percentages of linguistically isolated households was associated with progressively lower subhazards of activation both in the overall population (reference: <1% linguistically isolated households; 1%-4.9% linguistically isolated: subhazard ratio, 0.89; 95% confidence interval, 0.86 to 0.93; 5%-9.9% linguistically isolated: subhazard ratio, 0.83; 95% confidence interval, 0.80 to 0.87; 10%-19.9% linguistically isolated: subhazard ratio, 0.76; 95% confidence interval, 0.72 to 0.80; and ≥20% linguistically isolated: subhazard ratio, 0.71; 95% confidence interval, 0.67 to 0.76) and among candidates designated temporarily inactive due to an incomplete transplant evaluation. CONCLUSIONS Our findings indicate that candidates residing in linguistically isolated communities are less likely to complete candidate evaluations and achieve active waitlist status.
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Affiliation(s)
- Efrain Talamantes
- Department of Internal Medicine, University of California, Davis School of Medicine, Sacramento, California
| | - Keith C. Norris
- Division of Nephrology, Department of Medicine
- Division of General Internal Medicine and Health Services, Department of Medicine, and
| | - Carol M. Mangione
- Division of General Internal Medicine and Health Services, Department of Medicine, and
| | | | - Amy D. Waterman
- Division of Nephrology, Department of Medicine
- Kidney Transplant Research Program, Division of Nephrology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; and
| | - John D. Peipert
- Division of Nephrology, Department of Medicine
- Kidney Transplant Research Program, Division of Nephrology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; and
| | - Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine
- Kidney Transplant Research Program, Division of Nephrology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; and
| | - Edmund Huang
- Division of Nephrology, Department of Medicine
- Kidney Transplant Research Program, Division of Nephrology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; and
- Division of Nephrology, Department of Medicine, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
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Patzer RE, Smith K, Basu M, Gander J, Mohan S, Escoffery C, Plantinga L, Melanson T, Kalloo S, Green G, Berlin A, Renville G, Browne T, Turgeon N, Caponi S, Zhang R, Pastan S. The ASCENT (Allocation System Changes for Equity in Kidney Transplantation) Study: a Randomized Effectiveness-Implementation Study to Improve Kidney Transplant Waitlisting and Reduce Racial Disparity. Kidney Int Rep 2017; 2:433-441. [PMID: 28845470 PMCID: PMC5568836 DOI: 10.1016/j.ekir.2017.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION The United Network for Organ Sharing (UNOS) implemented a new Kidney Allocation System (KAS) in December 2014 that is expected to substantially reduce racial disparities in kidney transplantation among waitlisted patients. However, not all dialysis facility clinical providers and end stage renal disease (ESRD) patients are aware of how the policy change could improve access to transplant. METHODS We describe the ASCENT (Allocation System Changes for Equity in KidNey Transplantation) study, a randomized controlled effectiveness-implementation study designed to test the effectiveness of a multicomponent intervention to improve access to the early steps of kidney transplantation among dialysis facilities across the United States. The multicomponent intervention consists of an educational webinar for dialysis medical directors, an educational video for patients and an educational video for dialysis staff, and a dialysis-facility specific transplant performance feedback report. Materials will be developed by a multidisciplinary dissemination advisory board and will undergo formative testing in dialysis facilities across the United States. RESULTS This study is estimated to enroll ~600 U.S. dialysis facilities with low waitlisting in all 18 ESRD Networks. The co-primary outcomes include change in waitlisting, and waitlist disparity at 1 year; secondary outcomes include changes in facility medical director knowledge about KAS, staff training regarding KAS, patient education regarding transplant, and a medical director's intent to refer patients for transplant evaluation. CONCLUSION The results from the ASCENT study will demonstrate the feasibility and effectiveness of a multicomponent intervention designed to increase access to the deceased-donor kidney waitlist and reduce racial disparities in waitlisting.
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Affiliation(s)
- Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322.,Department of Epidemiology, Rollins School of Public Health, Emory University School of Medicine 1518 Clifton Road Atlanta, GA 30322.,Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University School of Medicine, 1518 Clifton Road, Atlanta, GA 30322
| | - Kayla Smith
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322
| | - Mohua Basu
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322
| | - Jennifer Gander
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, College of Physicians & Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, 622 West 169th Street, New York, NY 10032
| | - Cam Escoffery
- Department of Epidemiology, Rollins School of Public Health, Emory University School of Medicine 1518 Clifton Road Atlanta, GA 30322
| | - Laura Plantinga
- Department of Medicine, Division of Renal Medicine, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322
| | - Taylor Melanson
- Department of Health Policy Management, Rollins School of Public Health, Emory School of Medicine, 1518 Clifton Road, Atlanta, GA 30322
| | - Sean Kalloo
- Department of Medicine, Division of Nephrology, College of Physicians & Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, 622 West 169th Street, New York, NY 10032
| | - Gary Green
- American Association of Kidney Patients, 2701 N. Rocky Point Drive, Suite 150, Tampa, FL 33607
| | - Alex Berlin
- Southeastern Kidney Transplant Coalition, Atlanta, GA 30322
| | - Gary Renville
- National Kidney Foundation, 270 Peachtree St NE #1040, Atlanta, GA 30303
| | - Teri Browne
- University of South Carolina, College of Social Work, 902 Sumter Street, Columbia, SC 29208
| | - Nicole Turgeon
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322
| | - Susan Caponi
- US ESRD Network 2, 1979 Marcus Ave, Lake Success, NY 11042
| | - Rebecca Zhang
- Department of Biostatistics, Rollins School of Public Health, Emory University School of Medicine, 1518 Clifton Road, Atlanta, GA 30322
| | - Stephen Pastan
- Department of Medicine, Division of Renal Medicine, Emory University School of Medicine, 101 Woodruff Circle, 5101 Woodruff Memorial Research Building, Atlanta, GA 30322
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Plantinga LC, Pastan SO, Wilk AS, Krisher J, Mulloy L, Gibney EM, Patzer RE. Referral for Kidney Transplantation and Indicators of Quality of Dialysis Care: A Cross-sectional Study. Am J Kidney Dis 2016; 69:257-265. [PMID: 27881246 DOI: 10.1053/j.ajkd.2016.08.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 08/17/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND Dialysis facility performance measures to improve access to kidney transplantation are being considered. Referral of patients for kidney transplantation evaluation by the dialysis facility is one potential indicator, but limited data exist to evaluate whether referral is associated with existing dialysis facility quality indicators. STUDY DESIGN Cross-sectional study. SETTING & PARTICIPANTS 12,926 incident (July 2005 to September 2011) adult (aged 18-69 years) patients treated at 241 dialysis facilities with complete quality indicator information from US national registry data linked to transplantation referral data from all 3 Georgia kidney transplantation centers. FACTORS Facility performance on dialysis quality indicators (high, intermediate, and low tertiles). OUTCOME Percentages of patients referred within 1 year of dialysis therapy initiation at dialysis facility. RESULTS Overall, a median of 25.4% of patients were referred for kidney transplantation within 1 year of dialysis therapy initiation. Higher facility-level referral was associated with better performance with respect to standardized transplantation ratio (high, 28.6%; intermediate, 25.1%; and low, 22.9%; P=0.001) and percentage waitlisted (high, 30.7%; intermediate, 26.8%; and low, 19.2%; P<0.001). Facility-level referral was not associated with indicators of quality of care associated with dialysis therapy initiation, including percentage of incident patients being informed of transplantation options. For most non-transplantation-related indicators of high-quality care, including those capturing mortality, morbidity, and anemia management, better performance was not associated with higher facility-level transplantation referral. LIMITATIONS Potential ecologic fallacy and residual confounding. CONCLUSIONS Transplantation referral among patients at dialysis facilities does not appear to be associated with overall quality of dialysis care at the facility. Quality indicators related to kidney transplantation were positively associated with, but not entirely correspondent with, higher percentages of patients referred for kidney transplantation evaluation from dialysis facilities. These results suggest that facility-level referral, which is within the control of the dialysis facility, may provide information about the quality of dialysis care beyond current indicators.
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Affiliation(s)
- Laura C Plantinga
- Department of Medicine, Emory University, Atlanta, GA; Department of Epidemiology, Emory University, Atlanta, GA.
| | - Stephen O Pastan
- Department of Medicine, Emory University, Atlanta, GA; Emory Transplant Center, Emory Healthcare, Atlanta, GA
| | - Adam S Wilk
- Department of Health Policy & Management, Emory University, Atlanta, GA
| | | | - Laura Mulloy
- Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA
| | - Eric M Gibney
- Piedmont Transplant Institute, Piedmont Healthcare, Atlanta, GA
| | - Rachel E Patzer
- Department of Epidemiology, Emory University, Atlanta, GA; Emory Transplant Center, Emory Healthcare, Atlanta, GA; Department of Surgery, Emory University, Atlanta, GA
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Patzer RE, Paul S, Plantinga L, Gander J, Sauls L, Krisher J, Mulloy LL, Gibney EM, Browne T, Zayas CF, McClellan WM, Arriola KJ, Pastan SO. A Randomized Trial to Reduce Disparities in Referral for Transplant Evaluation. J Am Soc Nephrol 2016; 28:935-942. [PMID: 27738125 DOI: 10.1681/asn.2016030320] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 08/01/2016] [Indexed: 11/03/2022] Open
Abstract
Georgia has the lowest kidney transplant rates in the United States and substantial racial disparities in transplantation. We determined the effectiveness of a multicomponent intervention to increase referral of patients on dialysis for transplant evaluation in the Reducing Disparities in Access to kidNey Transplantation Community Study (RaDIANT), a randomized, dialysis facility-based, controlled trial involving >9000 patients receiving dialysis from 134 dialysis facilities in Georgia. In December of 2013, we selected dialysis facilities with either low transplant referral or racial disparity in referral. The intervention consisted of transplant education and engagement activities targeting dialysis facility leadership, staff, and patients conducted from January to December of 2014. We examined the proportion of patients with prevalent ESRD in each facility referred for transplant within 1 year as the primary outcome, and disparity in the referral of black and white patients as a secondary outcome. Compared with control facilities, intervention facilities referred a higher proportion of patients for transplant at 12 months (adjusted mean difference [aMD], 7.3%; 95% confidence interval [95% CI], 5.5% to 9.2%; odds ratio, 1.75; 95% CI, 1.36 to 2.26). The difference between intervention and control facilities in the proportion of patients referred for transplant was higher among black patients (aMD, 6.4%; 95% CI, 4.3% to 8.6%) than white patients (aMD, 3.7%; 95% CI, 1.6% to 5.9%; P<0.05). In conclusion, this intervention increased referral and improved equity in kidney transplant referral for patients on dialysis in Georgia; long-term follow-up is needed to determine whether these effects led to more transplants.
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Affiliation(s)
- Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia; .,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Department of Medicine, Division of Renal Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Laura Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Department of Medicine, Division of Renal Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jennifer Gander
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia
| | - Leighann Sauls
- Southeastern Kidney Council, Inc., End Stage Renal Disease Network 6, Raleigh, North Carolina
| | - Jenna Krisher
- Southeastern Kidney Council, Inc., End Stage Renal Disease Network 6, Raleigh, North Carolina
| | - Laura L Mulloy
- Division of Nephrology, Hypertension, and Transplant, Augusta University, Augusta, Georgia
| | | | - Teri Browne
- University of South Carolina College of Social Work, Columbia, South Carolina; and
| | - Carlos F Zayas
- Division of Nephrology, Hypertension, and Transplant, Augusta University, Augusta, Georgia
| | - William M McClellan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.,Department of Medicine, Division of Renal Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kimberly Jacob Arriola
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Atlanta, Georgia
| | - Stephen O Pastan
- Department of Medicine, Division of Renal Medicine, Emory University School of Medicine, Atlanta, Georgia
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Hisam B, Zogg CK, Chaudhary MA, Ahmed A, Khan H, Selvarajah S, Torain MJ, Changoor NR, Haider AH. From understanding to action: interventions for surgical disparities. J Surg Res 2016; 200:560-78. [DOI: 10.1016/j.jss.2015.09.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 08/28/2015] [Accepted: 09/14/2015] [Indexed: 11/26/2022]
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Kucirka LM, Segev DL. The Other Half of Informed Consent: Transplant Education Practices in Dialysis Centers. Clin J Am Soc Nephrol 2015; 10:1507-9. [PMID: 26292695 DOI: 10.2215/cjn.08280815] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Lauren M Kucirka
- Department of Surgery, Johns Hopkins School of Medicine, and Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins School of Medicine, and Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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Patzer RE, Plantinga LC, Paul S, Gander J, Krisher J, Sauls L, Gibney EM, Mulloy L, Pastan SO. Variation in Dialysis Facility Referral for Kidney Transplantation Among Patients With End-Stage Renal Disease in Georgia. JAMA 2015; 314:582-94. [PMID: 26262796 PMCID: PMC4571496 DOI: 10.1001/jama.2015.8897] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Dialysis facilities in the United States are required to educate patients with end-stage renal disease about all treatment options, including kidney transplantation. Patients receiving dialysis typically require a referral for kidney transplant evaluation at a transplant center from a dialysis facility to start the transplantation process, but the proportion of patients referred for transplantation is unknown. OBJECTIVE To describe variation in dialysis facility-level referral for kidney transplant evaluation and factors associated with referral among patients initiating dialysis in Georgia, the US state with the lowest kidney transplantation rates. DESIGN, SETTING, AND PARTICIPANTS Examination of United States Renal Data System data from a cohort of 15,279 incident, adult (18-69 years) patients with end-stage renal disease from 308 Georgia dialysis facilities from January 2005 to September 2011, followed up through September 2012, linked to kidney transplant referral data collected from adult transplant centers in Georgia in the same period. MAIN OUTCOMES AND MEASURES Referral for kidney transplant evaluation within 1 year of starting dialysis at any of the 3 Georgia transplant centers was the primary outcome; placement on the deceased donor waiting list was also examined. RESULTS The median within-facility percentage of patients referred within 1 year of starting dialysis was 24.4% (interquartile range, 16.7%-33.3%) and varied from 0% to 75.0%. Facilities in the lowest tertile of referral (<19.2%) were more likely to treat patients living in high-poverty neighborhoods (absolute difference, 21.8% [95% CI, 14.1%-29.4%]), had a higher patient to social worker ratio (difference, 22.5 [95% CI, 9.7-35.2]), and were more likely nonprofit (difference, 17.6% [95% CI, 7.7%-27.4%]) compared with facilities in the highest tertile of referral (>31.3%). In multivariable, multilevel analyses, factors associated with lower referral for transplantation, such as older age, white race, and nonprofit facility status, were not always consistent with the factors associated with lower waitlisting. CONCLUSIONS AND RELEVANCE In Georgia overall, a limited proportion of patients treated with dialysis were referred for kidney transplant evaluation between 2005 and 2011, but there was substantial variability in referral among facilities. Variables associated with referral were not always associated with waitlisting, suggesting that different factors may account for disparities in referral.
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Affiliation(s)
- Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia2Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia3Emory Transplant Center, Atlanta, Georgia
| | - Laura C Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia4Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Jennifer Gander
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jenna Krisher
- Southeastern Kidney Council Inc of End Stage Renal Disease Network 6, Raleigh, North Carolina
| | - Leighann Sauls
- Southeastern Kidney Council Inc of End Stage Renal Disease Network 6, Raleigh, North Carolina
| | - Eric M Gibney
- Piedmont Transplant Institute, Piedmont Healthcare, Atlanta, Georgia
| | - Laura Mulloy
- Division of Nephrology, Department of Medicine, Georgia Regents University, Augusta
| | - Stephen O Pastan
- Emory Transplant Center, Atlanta, Georgia4Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Gander J, Browne T, Plantinga L, Pastan SO, Sauls L, Krisher J, Patzer RE. Dialysis Facility Transplant Philosophy and Access to Kidney Transplantation in the Southeast. Am J Nephrol 2015; 41:504-11. [PMID: 26278585 DOI: 10.1159/000438463] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 07/06/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Little is known about the impact of dialysis facility treatment philosophy on access to transplant. The aim of our study was to determine the relationship between the dialysis facility transplant philosophy and facility-level access to kidney transplant waitlisting. METHODS A 25-item questionnaire administered to Southeastern dialysis facilities (n = 509) in 2012 captured the facility transplant philosophy (categorized as 'transplant is our first choice', 'transplant is a great option for some', and 'transplant is a good option, if the patient is interested'). Facility-level waitlisting and facility characteristics were obtained from the 2008-2011 Dialysis Facility Report. Multivariable logistic regression was used to examine the association between the dialysis facility transplant philosophy and facility waitlisting performance (dichotomized using the national median), where low performance was defined as fewer than 21.7% of dialysis patients waitlisted within a facility. RESULTS Fewer than 25% (n = 124) of dialysis facilities reported 'transplant is our first option'. A total of 131 (31.4%) dialysis facilities in the Southeast were high-performing facilities with respect to waitlisting. Adjusted analysis showed that facilities who reported 'transplant is our first option' were twice (OR 2.0; 95% CI 1.0-3.9) as likely to have high waitlisting performance compared to facilities who reported that 'transplant is a good option, if the patient is interested'. CONCLUSIONS Facilities with staff who had a more positive transplant philosophy were more likely to have better facility waitlisting performance. Future prospective studies are needed to further investigate if improving the kidney transplant philosophy in dialysis facilities improves access to transplantation.
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