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Pollock MD, Stauffer N, Lee HJ, Chow SC, Satoru I, Moats L, Swan-Nesbit S, Li Y, Roberts JK, Ellis MJ, Diamantidis CJ, Docherty SL, Chambers ET. MyKidneyCoach, Patient Activation, and Clinical Outcomes in Diverse Kidney Transplant Recipients: A Randomized Control Pilot Trial. Transplant Direct 2023; 9:e1462. [PMID: 36935874 PMCID: PMC10019211 DOI: 10.1097/txd.0000000000001462] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/17/2023] [Accepted: 02/01/2023] [Indexed: 03/17/2023] Open
Abstract
Kidney transplant (KT) recipients who are not actively engaged in their care and lack self-management skills have poor transplant outcomes, which are disproportionately observed among Black KT recipients. This pilot study aimed to determine whether the MyKidneyCoach app, an mHealth intervention that provides self-management monitoring and coaching, improved patient activation, engagement, and nutritional behaviors in a diverse KT population. Methods This was a randomized, age-stratified, parallel-group, attention-control, pilot study in post-KT patients. Participants were randomized into the attention-control with access to MyKidneyCoach for education and self-management (n = 9) or the intervention with additional tailored nurse coaching (n = 7). Feasibility, acceptability, and clinical outcomes were assessed. Results The acceptability of MyKidneyCoach by System Usability Scale was 67.5 (95% confidence interval [CI], 59.1-75.9). Completion rates based on actively using MyKidneyCoach were 81% (95% CI, 57%-93%) and study retention rate of 73%. Patient activation measure significantly increased overall by a mean of 11 points (95% CI, 3.2-18.8). Additionally, Black patients (n = 7) had higher nutrition self-efficacy scores of 80.5 (95% CI, 74.4-86.7) compared with 75.6 (95% CI, 71.1-80.1) in non-Black patients (n = 9) but lower patient activation measure scores of 69.3 (95% CI, 56.3-82.3) compared with 71.8 (95% CI, 62.5-81) in non-Black patients after 3 mo. Conclusions MyKidneyCoach was easy to use and readily accepted with low attrition, and improvements were demonstrated in patient-reported outcomes. Both Black and non-Black participants using MyKidneyCoach showed improvement in self-management competencies; thus, this intervention may help reduce healthcare inequities in KT.
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Affiliation(s)
| | - Nicolas Stauffer
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Shein-Chung Chow
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Ito Satoru
- Department of Surgery, Duke University, Durham, NC
| | | | | | - Yan Li
- Department of Pathology, Duke University, Durham, NC
| | | | | | | | | | - Eileen T. Chambers
- Department of Surgery, Duke University, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
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2
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Kadatz M, Lan JH, Brar S, Vaishnav S, Chang DT, Gill J, Gill JS. Transplantation of Patients With Long Dialysis Vintage in the Current Deceased Donor Kidney Allocation System (KAS). Am J Kidney Dis 2022; 80:319-329.e1. [PMID: 35311661 DOI: 10.1053/j.ajkd.2022.01.429] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 01/14/2022] [Indexed: 01/27/2023]
Abstract
RATIONALE & OBJECTIVE In 2014 the wait-time calculation for deceased donor kidney transplantation in the United States was changed from the date of first waitlisting to the date of first maintenance dialysis treatment with the aim of minimizing disparities in access to transplantation. This study examined the impact of this policy on access to transplantation, patient survival, and transplant outcomes among patients treated with maintenance dialysis for a prolonged duration before waitlisting. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Patients identified in the US Renal Data System between 2008 and 2018 aged 18-70 years and in the 95th percentile of dialysis treatment duration (≥6.5 years) before waitlisting. EXPOSURE Waitlisting for transplantation before versus after implementation of the policy. OUTCOME Time from date of waitlisting to deceased donor transplantation and death, and from date of transplantation to all cause graft loss. ANALYTICAL APPROACH Univariate and multivariable time to event analyses. RESULTS Patients waitlisted after the policy change had a higher likelihood of deceased donor transplantation (HR, 3.12 [95% CI, 2.90-3.37]) and lower risk of death (HR, 0.74 [95% CI, 0.63-0.87]). The risk of graft loss was lower in the post-kidney allocation system (KAS) cohort (HR, 0.66 [95% CI, 0.55-0.80]). The proportion of adult patients treated with dialysis ≥6.5 years who were never waitlisted for transplantation remained high (73%) and did not decrease after the policy implementation. LIMITATIONS Cannot determine causality in this observational study. CONCLUSIONS The policy change was associated with an increase in deceased donor transplantation and marked improvement in patient survival for patients waitlisted after long periods of dialysis treatment without decreasing the utility of available deceased donor kidney supply. The policy was not associated with increased waitlisting of this disadvantaged population.
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Affiliation(s)
- Matthew Kadatz
- Division of Nephrology, Kidney Transplant Program, University of British Columbia, Vancouver, British Columbia, Canada; Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - James H Lan
- Division of Nephrology, Kidney Transplant Program, University of British Columbia, Vancouver, British Columbia, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Sandeep Brar
- Division of Nephrology, Kidney Transplant Program, University of British Columbia, Vancouver, British Columbia, Canada; Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California
| | - Sakshi Vaishnav
- Division of Nephrology, Kidney Transplant Program, University of British Columbia, Vancouver, British Columbia, Canada
| | - Doris T Chang
- Providence Health Research Institute, Vancouver, British Columbia, Canada
| | - Jagbir Gill
- Division of Nephrology, Kidney Transplant Program, University of British Columbia, Vancouver, British Columbia, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada; School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada; Providence Health Research Institute, Vancouver, British Columbia, Canada; Centre for Health Evaluation and Outcomes Sciences, Vancouver, British Columbia, Canada
| | - John S Gill
- Division of Nephrology, Kidney Transplant Program, University of British Columbia, Vancouver, British Columbia, Canada; Providence Health Research Institute, Vancouver, British Columbia, Canada; Centre for Health Evaluation and Outcomes Sciences, Vancouver, British Columbia, Canada; Tufts Medical Center, Boston, Massachusetts.
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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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4
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Carter AJ, Reed RD, Kale AC, Qu H, Kumar V, Hanaway MJ, Cannon RM, Locke JE. Impact of Social Vulnerability on Access to Educational Programming Designed to Enhance Living Donation. Prog Transplant 2021; 31:305-313. [PMID: 34713750 DOI: 10.1177/15269248211046014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Transplant candidate participation in the Living Donor Navigator Program is associated with an increased likelihood of achieving living donor kidney transplantation; yet not every transplant candidate participates in navigator programming. RESEARCH QUESTION We sought to assess interest and ability to participate in the Living Donor Navigator Program by the degree of social vulnerability. DESIGN Eighty-two adult kidney-only candidates initiating evaluation at our center provided Likert-scaled responses to survey questions on interest and ability to participate in the Living Donor Navigator Program. Surveys were linked at the participant-level to the Centers for Disease Control and Prevention Social Vulnerability Index and county health rankings and overall social vulnerability and subthemes, individual barriers, telehealth capabilities/ knowledge, interest, and ability to participate were assessed utilizing nonparametric Wilcoxon ranks sums tests, chi-square, and Fisher's exact tests. RESULTS Participants indicating distance as a barrier to participation in navigator programming lived approximately 82 miles farther from our center. Disinterested participants lived in areas with the highest social vulnerability, higher physical inactivity rates, lower college education rates, and higher uninsurance (lack of insurance) and unemployment rates. Similarly, participants without a computer, who never heard of telehealth, and who were not encouraged to participate in telehealth resided in areas of highest social vulnerability. CONCLUSION These data suggest geography combined with being from under-resourced areas with high social vulnerability was negatively associated with health care engagement. Geography and poverty may be surrogates for lower health literacy and fewer health care interactions.
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Affiliation(s)
- Alexis J Carter
- 9968University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - Rhiannon D Reed
- 9968University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - A Cozette Kale
- 9968University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - Haiyan Qu
- 9968University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - Vineeta Kumar
- 9968University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - Michael J Hanaway
- 9968University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - Robert M Cannon
- 9968University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - Jayme E Locke
- 9968University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
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Srinivas TR, Coran JJ, Thatcher EJ, Patton B, Dunn B, Palakodeti S, Zeiger T, Dobbs BN, Reese V, Runnels P, Sarabu N, Pronovost PJ. Redesigning Kidney Disease Care to Improve Value Delivery. Popul Health Manag 2021; 25:592-600. [PMID: 34529502 DOI: 10.1089/pop.2021.0112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This article describes the articulation, development, and deployment of a machine learning (ML) model-driven value solution for chronic kidney disease (CKD) in a health system. The ML model activated an electronic medical record (EMR) trigger that alerted CKD patients to seek primary care. Simultaneously, primary care physicians (PCPs) received an alert that a CKD patient needed an appointment. Using structured checklists, PCPs addressed and controlled comorbid conditions, reconciled drug dosing and choice to CKD stage, and ordered prespecified laboratory and imaging tests pertinent to CKD. After completion of checklist prescribed tasks, PCPs referred patients to nephrology. CKD patients had multiple comorbidities and ML recognition of CKD provided a facile insight into comorbid burden. Operational results of this program have exceeded expectations and the program is being expanded to the entire health system. This paradigm of ML-driven, checklist-enabled care can be used agnostic of EMR platform to deliver value in CKD through structured engagement of complexity in health systems.
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Affiliation(s)
| | - Justin J Coran
- Case Western Reserve University, Cleveland, Ohio, USA.,University Hospitals, Cleveland, Ohio, USA
| | | | | | | | | | | | | | | | | | | | - Peter J Pronovost
- Case Western Reserve University, Cleveland, Ohio, USA.,University Hospitals, Cleveland, Ohio, USA
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6
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McPherson LJ, Walker ER, Lee YTH, Gander JC, Wang Z, Reeves-Daniel AM, Browne T, Ellis MJ, Rossi AP, Pastan SO, Patzer RE. Dialysis Facility Profit Status and Early Steps in Kidney Transplantation in the Southeastern United States. Clin J Am Soc Nephrol 2021; 16:926-936. [PMID: 34039566 PMCID: PMC8216615 DOI: 10.2215/cjn.17691120] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/22/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Dialysis facilities in the United States play a key role in access to kidney transplantation. Previous studies reported that patients treated at for-profit facilities are less likely to be waitlisted and receive a transplant, but their effect on early steps in the transplant process is unknown. The study's objective was to determine the association between dialysis facility profit status and critical steps in the transplantation process in Georgia, North Carolina, and South Carolina. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this retrospective cohort study, we linked referral and evaluation data from all nine transplant centers in the Southeast with United States Renal Data System surveillance data. The cohort study included 33,651 patients with kidney failure initiating dialysis from January 1, 2012 to August 31, 2016. Patients were censored for event (date of referral, evaluation, or waitlisting), death, or end of study (August 31, 2017 for referral and March 1, 2018 for evaluation and waitlisting). The primary exposure was dialysis facility profit status: for profit versus nonprofit. The primary outcome was referral for evaluation at a transplant center after dialysis initiation. Secondary outcomes were start of evaluation at a transplant center after referral and waitlisting. RESULTS Of the 33,651 patients with incident kidney failure, most received dialysis treatment at a for-profit facility (85%). For-profit (versus nonprofit) facilities had a lower cumulative incidence difference for referral within 1 year of dialysis (-4.5%; 95% confidence interval, -6.0% to -3.2%). In adjusted analyses, for-profit versus nonprofit facilities had lower referral (hazard ratio, 0.84; 95% confidence interval, 0.80 to 0.88). Start of evaluation within 6 months of referral (-1.0%; 95% confidence interval, -3.1% to 1.3%) and waitlisting within 6 months of evaluation (1.0%; 95% confidence interval, -1.2 to 3.3) did not meaningfully differ between groups. CONCLUSIONS Findings suggest lower access to referral among patients dialyzing in for-profit facilities in the Southeast United States, but no difference in starting the evaluation and waitlisting by facility profit status.
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Affiliation(s)
- Laura J. McPherson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Elizabeth R. Walker
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Yi-Ting Hana Lee
- Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia
| | - Jennifer C. Gander
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia
| | - Zhensheng Wang
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia,Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia
| | - Amber M. Reeves-Daniel
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Teri Browne
- College of Social Work, University of South Carolina, Columbia, South Carolina
| | - Matthew J. Ellis
- Department of Medicine, Duke University, Durham, North Carolina,Department of Surgery, Duke University, Durham, North Carolina
| | - Ana P. Rossi
- Department of Transplantation, Piedmont Transplant Institute, Piedmont Healthcare, Atlanta, Georgia
| | - Stephen O. Pastan
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E. Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia,Department of Surgery, Emory University School of Medicine, Atlanta, Georgia,Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia
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7
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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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8
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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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9
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Kim SJ, Gill JS, Knoll G, Campbell P, Cantarovich M, Cole E, Kiberd B. Referral for Kidney Transplantation in Canadian Provinces. J Am Soc Nephrol 2019; 30:1708-1721. [PMID: 31387925 DOI: 10.1681/asn.2019020127] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/20/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Patient referral to a transplant facility, a prerequisite for dialysis-treated patients to access kidney transplantation in Canada, is a subjective process that is not recorded in national dialysis or transplant registries. Patients who may benefit from transplant may not be referred. METHODS In this observational study, we prospectively identified referrals for kidney transplant in adult patients between June 2010 and May 2013 in 12 transplant centers, and linked these data to information on incident dialysis patients in a national registry. RESULTS Among 13,184 patients initiating chronic dialysis, the cumulative incidence of referral for transplant was 17.3%, 24.0%, and 26.8% at 1, 2, and 3 years after dialysis initiation, respectively; the rate of transplant referral was 15.8 per 100 patient-years (95% confidence interval, 15.1 to 16.4). Transplant referral varied more than three-fold between provinces, but it was not associated with the rate of deceased organ donation or median waiting time for transplant in individual provinces. In a multivariable model, factors associated with a lower likelihood of referral included older patient age, female sex, diabetes-related ESKD, higher comorbid disease burden, longer durations (>12.0 months) of predialysis care, and receiving dialysis at a location >100 km from a transplant center. Median household income and non-Caucasian race were not associated with a lower likelihood of referral. CONCLUSIONS Referral rates for transplantation varied widely between Canadian provinces but were not lower among patients of non-Caucasian race or with lower socioeconomic status. Standardization of transplantation referral practices and ongoing national reporting of referral may decrease disparities in patient access to kidney transplant.
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Affiliation(s)
- S Joseph Kim
- University Health Network, University of Toronto, Toronto, Canada
| | - John S Gill
- University of British Columbia, Vancouver, Canada; .,Division of Nephrology, Center for Health Evaluation and Outcome Sciences, Vancouver, Canada
| | - Greg Knoll
- University of Ottawa, Ottawa, Canada.,Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | | | - Edward Cole
- University Health Network, University of Toronto, Toronto, Canada
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10
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Advancing Transplantation: New Questions, New Possibilities in Kidney and Liver Transplantation. Transplantation 2018; 101 Suppl 2S:S1-S41. [PMID: 28125449 DOI: 10.1097/tp.0000000000001563] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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11
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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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12
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Mohan S, Chiles MC, Patzer RE, Pastan SO, Husain SA, Carpenter DJ, Dube GK, Crew RJ, Ratner LE, Cohen DJ. Factors leading to the discard of deceased donor kidneys in the United States. Kidney Int 2018; 94:187-198. [PMID: 29735310 PMCID: PMC6015528 DOI: 10.1016/j.kint.2018.02.016] [Citation(s) in RCA: 164] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 01/31/2018] [Accepted: 02/01/2018] [Indexed: 01/22/2023]
Abstract
The proportion of deceased donor kidneys procured for transplant but subsequently discarded has been growing steadily in the United States, but factors contributing to the rising discard rate remain unclear. To assess the reasons for and probability of organ discard we assembled a cohort of 212,305 deceased donor kidneys recovered for transplant from 2000-2015 in the SRTR registry that included 36,700 kidneys that were discarded. 'Biopsy Findings' (38.2%) was the most commonly reported reason for discard. The median Kidney Donor Risk Index of discarded kidneys was significantly higher than transplanted organs (1.78 vs 1.12), but a large overlap in the quality of discarded and transplanted kidneys was observed. Kidneys of donors who were older, female, Black, obese, diabetic, hypertensive or HCV-positive experienced a significantly increased odds of discard. Kidneys from donors with multiple unfavorable characteristics were more likely to be discarded, whereas unilaterally discarded kidneys had the most desirable donor characteristics and the recipients of their partner kidneys experienced a one-year death-censored graft survival rate over 90%. There was considerable geographic variation in the odds of discard across the United States, which further supports the notion that factors beyond organ quality contributed to kidney discard. Thus, while the discard of a small fraction of organs procured from donors may be inevitable, the discard of potentially transplantable kidneys needs to be avoided. This will require a better understanding of the factors contributing to organ discard in order to remove the disincentives to utilize less-than-ideal organs for transplantation.
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Affiliation(s)
- Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA.
| | - Mariana C Chiles
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Rachel E Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Emory University, Atlanta, Georgia, USA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Stephen O Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Emory University, Atlanta, Georgia, USA
| | - S Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA; The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Dustin J Carpenter
- Department of Surgery, Division of Transplantation, Columbia University Medical Center, New York, New York, USA
| | - Geoffrey K Dube
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - R John Crew
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - Lloyd E Ratner
- Department of Surgery, Division of Transplantation, Columbia University Medical Center, New York, New York, USA
| | - David J Cohen
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
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13
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Flemming SSC, Redmond N, Williamson DHZ, Thompson NJ, Perryman JP, Patzer RE, Arriola KJ. Understanding the pros and cons of organ donation decision-making: Decisional balance and expressing donation intentions among African Americans. J Health Psychol 2018; 25:1612-1623. [DOI: 10.1177/1359105318766212] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Increasing public commitment to organ donation is critical to improving donor kidney availability for end-stage renal disease patients desiring transplant. This study surveyed ( N = 1339) African Americans, measuring perceived pros relative to cons of organ donation, to evaluate an existing Transtheoretical Model decisional balance scale and associations between decisional balance and expressing donation intentions. Findings supported the existing scale structure. More positive decisional balance ratios were associated with 1.76 times the odds of expressing intentions (95% confidence interval = 1.52–2.04). Pros were more strongly linked to donation intentions than cons. Greater understanding of organ donation decision-making is valuable for informing interventions that encourage donation.
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Affiliation(s)
| | | | | | | | | | - Rachel E Patzer
- Emory University, USA
- Emory University School of Medicine, USA
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14
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15
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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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16
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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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17
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Cantrelle C, Dorent R, Savoye E, Tuppin P, Lebreton G, Legeai C, Bastien O. Between-center disparities in access to heart transplantation in France: contribution of candidate and center factors - A comprehensive cohort study. Transpl Int 2017; 31:386-397. [PMID: 29130535 DOI: 10.1111/tri.13093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 09/20/2017] [Accepted: 11/08/2017] [Indexed: 11/29/2022]
Abstract
Transplantation represents the last option for patients with advanced heart failure. We assessed between-center disparities in access to heart transplantation in France 1 year after registration and evaluated the contribution of factors to these disparities. Adults (n = 2347) registered on the French national waiting list between January 1, 2010, and December 31, 2014, in the 23 transplant centers were included. Associations between candidate and transplant center characteristics and access to transplantation were assessed by proportional hazards frailty models. Candidate blood groups O and A, sensitization, and body mass index ≥30 kg/m2 were independently associated with lower access to transplantation, while female gender, severity of heart failure, and high serum bilirubin levels were independently associated with greater access to transplantation. Center factors significantly associated with access to transplantation were heart donation rate in the donation service area, proportion of high-urgency candidates among listed patients, and donor heart offer decline rate. Between-center variability in access to transplantation increased by 5% after adjustment for candidate factors and decreased by 57% after adjustment for center factors. After adjustment for candidate and center factors, five centers were still outside of normal variability. These findings will be taken into account in the future French heart allocation system.
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Affiliation(s)
| | | | | | - Philippe Tuppin
- Caisse Nationale d'Assurance Maladie des Travailleurs Salariés, Paris, France
| | - Guillaume Lebreton
- Service de Chirurgie Cardio-Vasculaire, Assistance Publique Hôpitaux de Paris, Hôpital de la Pitié Salpêtrière, Paris, France
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18
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Schold JD, Buccini LD, Phelan MP, Jay CL, Goldfarb DA, Poggio ED, Sedor JR. Building an Ideal Quality Metric for ESRD Health Care Delivery. Clin J Am Soc Nephrol 2017; 12:1351-1356. [PMID: 28515155 PMCID: PMC5544503 DOI: 10.2215/cjn.01020117] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | | | | | | | - David A. Goldfarb
- Glickman Urological and Kidney Institutes, Cleveland Clinic, Cleveland, Ohio
| | - Emilio D. Poggio
- Glickman Urological and Kidney Institutes, Cleveland Clinic, Cleveland, Ohio
| | - John R. Sedor
- Departments of Medicine, Physiology and Biophysics, Case Western Reserve University, Rammelkamp Center for Research and Education, MetroHealth System, Cleveland, Ohio
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19
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Olufajo OA, Adler JT, Yeh H, Zeliadt SB, Hernandez RA, Tullius SG, Backhus L, Salim A. Disparities in kidney transplantation across the United States: Does residential segregation play a role? Am J Surg 2017; 213:656-661. [PMID: 28228248 DOI: 10.1016/j.amjsurg.2016.10.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 10/07/2016] [Accepted: 10/21/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although residential segregation has been implicated in various negative health outcomes, its association with kidney transplantation has not been examined. METHODS Age- and sex-standardized kidney transplantation rates were calculated from the Scientific Registry of Transplant Recipients, 2000-2013. Population characteristics including segregation indices were derived from the 2010 U.S. Census data and the U.S. Renal Data System. Separate multivariable Poisson regression models were constructed to identify factors independently associated with kidney transplantation among Blacks and Whites. RESULTS Median age- and sex-standardized kidney transplantation rates were 114 per 100,000 for Blacks and 38 per 100,000 for Whites. 16.1% of the U.S. population lived in counties with high segregation. There was no difference in the kidney transplantation rates across the levels of segregation among Blacks and Whites. CONCLUSION Factors other than residential segregation may play roles in kidney transplantation disparities. Continued efforts to identify these factors may be beneficial in reducing transplantation disparities across the U.S. SUMMARY Using the Scientific Registry of Transplant Recipients and U.S. census data, we aimed to determine whether residential segregation was associated with kidney transplantation rates. We found that there was no association between residential segregation and kidney transplantation rates.
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Affiliation(s)
- Olubode A Olufajo
- Division of Trauma, Burn and Surgical Critical Care, Brigham and Women's Hospital, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Joel T Adler
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Heidi Yeh
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Steven B Zeliadt
- Department of Health Services, University of Washington, Seattle, WA, USA
| | | | - Stefan G Tullius
- Division of Transplant Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Leah Backhus
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Ali Salim
- Division of Trauma, Burn and Surgical Critical Care, Brigham and Women's Hospital, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA.
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20
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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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21
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Ozieh MN, Bishu KG, Walker RJ, Campbell JA, Egede LE. Geographic variation in access among adults with kidney disease: evidence from medical expenditure panel survey, 2002-2011. BMC Health Serv Res 2016; 16:585. [PMID: 27756393 PMCID: PMC5069810 DOI: 10.1186/s12913-016-1844-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 10/12/2016] [Indexed: 11/10/2022] Open
Abstract
Background To understand geographic variation in access to care over time in patients with kidney disease. Methods We analyzed 4404 (weighted sample of 4,251,129) adults with kidney disease from the United States using the Medical Expenditure Panel Survey over 10 years. Three dependent variables were created to investigate variation in access: usual source of care, overall medical access to care, which took into account usual source of care, ability to get care, and delay in care, and prescription access, which took into account ability to get prescriptions and delay in getting prescriptions. Multiple logistic regression was used with geographic region as the main independent variable, adjusting for relevant covariates. Results Compared to the Northeast region, adults living in the Midwest (OR = 0.56; 95 % CI 0.35–0.89), South (OR = 0.48; 95 % CI 0.32–0.72) and West (OR = 0.53; 95 % CI 0.34–0.84) had significantly lower odds of reporting usual source of care. For the combined access measure, compared to Northeast, adults in Midwest (OR = 0.60; 95 % CI 0.40–0.88), South (OR = 0.62; 95 % CI 0.44–0.88) and West (OR = 0.50; 95 % CI 0.34–0.72) had significantly lower odds of medical access to care. Region was not significantly associated with the odds of having prescription access, though a significant increase in prescription access was observed over time. Conclusions Geographic variation in access to care among adults with kidney disease exists independent of income, education, insurance and comorbid conditions, with those in the South least likely to have a usual source of care and those in the West least likely to have overall access to care when compared to the Northeast United States.
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Affiliation(s)
- Mukoso N Ozieh
- Center for Health Disparities Research, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.,Department of Medicine, Division of General Internal Medicine and Geriatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Kinfe G Bishu
- Center for Health Disparities Research, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.,Department of Medicine, Division of General Internal Medicine and Geriatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Rebekah J Walker
- Center for Health Disparities Research, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.,Department of Medicine, Division of General Internal Medicine and Geriatrics, Medical University of South Carolina, Charleston, SC, USA.,Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Jennifer A Campbell
- Center for Health Disparities Research, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.,Department of Medicine, Division of General Internal Medicine and Geriatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Leonard E Egede
- Center for Health Disparities Research, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA. .,Department of Medicine, Division of General Internal Medicine and Geriatrics, Medical University of South Carolina, Charleston, SC, USA. .,Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
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22
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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: 84] [Impact Index Per Article: 10.5] [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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Wallace EL, Lea J, Chaudhary NS, Griffin R, Hammelman E, Cohen J, Sloand JA. Home Dialysis Utilization Among Racial and Ethnic Minorities in the United States at the National, Regional, and State Level. Perit Dial Int 2016; 37:21-29. [PMID: 27680759 DOI: 10.3747/pdi.2016.00025] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 03/05/2016] [Indexed: 11/15/2022] Open
Abstract
♦ BACKGROUND: United States Renal Data System (USRDS) data from 2014 show that African Americans (AA) are underrepresented in the home dialysis population, with 6.4% versus 9.2% utilization in the general populace. This racial disparity may be inaccurately ascribed to the nation as a whole if regional and inter-state variability exists. This investigation sought to examine home dialysis utilization by minority Medicare beneficiary populations across the US nationally, regionally, and by individual state. ♦ METHODS: The 2012 Medicare 100% Outpatient Standard Analytic File was used to identify all Medicare fee-for-service (FFS) patients, with state of residence and race, receiving an outpatient dialysis facility bill type. Peritoneal dialysis (PD) and home hemodialysis (HHD) patients were identified using revenue and condition codes and were defined by having at least one claim during the year that met criteria for the category. Beneficiaries were counted once for each modality used that year. A home dialysis utilization ratio (UR) was calculated as the ratio of the proportion of a minority on PD or HHD within a geographic division to the proportion of Caucasians on PD or HHD within the same geographic division. A UR less than 1.00 indicated under-representation while a UR over 1.00 indicated over-representation. Utilization ratios were compared using a Poisson regression model. ♦ RESULTS: A total of 369,164 Medicare FFS dialysis patients were identified. Within the total cohort, AA were the most underrepresented minority on PD (UR 0.586; 95% confidence interval [CI]: 0.585 - 0.586; p < 0.0001), followed by Hispanics (UR 0.744; 95% CI 0.743 - 0.744; p < 0.0001). The underutilization of PD by AA and Hispanics could not be ascribed to any region of the US, as all regions of the US had UR < 1.00. Only Massachusetts had a UR > 1.00 for AA on PD. Peritoneal dialysis UR values for Asians and those self-identified as Other were 0.954; 95% CI 0.953 - 0.954 and 0.932; 95% CI 0.931 - 0.932, respectively. Nationally, all minorities utilized HHD less than Caucasians. However, more variability existed, with Asians utilizing more HHD than Caucasians in the Midwest. ♦ CONCLUSIONS: Although regional and interstate variability exists, there is near universal under-representation of AA and Hispanics in the home dialysis population, while Asians and Other demonstrate more interregional and interstate variability.
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Affiliation(s)
- Eric L Wallace
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Ninad S Chaudhary
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Russell Griffin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - James A Sloand
- Baxter Healthcare Corporation, Deerfield, IL, United States
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24
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Browne T, Amamoo A, Patzer RE, Krisher J, Well H, Gander J, Pastan SO. Everybody needs a cheerleader to get a kidney transplant: a qualitative study of the patient barriers and facilitators to kidney transplantation in the Southeastern United States. BMC Nephrol 2016; 17:108. [PMID: 27476111 PMCID: PMC4967312 DOI: 10.1186/s12882-016-0326-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 07/27/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Kidney transplantation (KTx) disparity is a significant problem in the United States, particularly in the Southeastern region. In response to this phenomenon, the Southeastern Kidney Transplant Coalition was created in 2011 to increase the KTx rate, and to reduce disparities in access to transplantation in the Southeast, by identifying and reducing barriers in the transplant process. METHODS To determine perceived barriers and facilitators to KTx that dialysis patients in this region experience, we conducted three focus groups with 40 total patients in Georgia, North Carolina, and South Carolina. RESULTS We identified two novel themes specific to Southeastern dialysis patients that describe the major barriers and facilitators to kidney transplantation: dialysis center approaches to patient education about KTx, and dialysis center advocacy and encouragement for KTx. In addition, themes related to barriers and facilitators of KTx were evident that were previously mentioned in the literature such as age, fear, knowing other patients with good or bad experiences with KTx, distrust of the KTx process equity, financial concerns and medical barriers. CONCLUSIONS Dialysis providers are encouraged to enhance their delivery of information and active assistance to underserved patients related to KTx.
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Affiliation(s)
- Teri Browne
- College of Social Work, University of South Carolina, 12 Hamilton, Columbia, SC, 29208, USA.
| | - Ahinee Amamoo
- Southeastern Kidney Council, 1000 St. Albans Drive, Suite 270, Raleigh, NC, 27609, USA
| | - Rachel E Patzer
- School of Medicine, Emory University, 101 Woodruff Circle, 5105 WMB, Atlanta, GA, 30322, USA
| | - Jenna Krisher
- Southeastern Kidney Council, 1000 St. Albans Drive, Suite 270, Raleigh, NC, 27609, USA
| | - Henry Well
- National Kidney Foundation, 508 Hampton Street, Columbia, SC, 29201, USA
| | - Jennifer Gander
- School of Medicine, Emory University, 101 Woodruff Circle, 5105 WMB, Atlanta, GA, 30322, USA
| | - Stephen O Pastan
- School of Medicine, Emory University, 101 Woodruff Circle, 5105 WMB, Atlanta, GA, 30322, USA
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Browne T, Patzer RE, Gander J, Amamoo MA, Krisher J, Sauls L, Pastan S. Kidney transplant referral practices in southeastern dialysis units. Clin Transplant 2016; 30:365-71. [PMID: 26782140 DOI: 10.1111/ctr.12693] [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] [Accepted: 01/09/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND The Southeastern Kidney Transplant Coalition was created in 2010 to improve kidney transplant (KTx) rates in Georgia, North Carolina, and South Carolina. To identify dialysis staff-reported barriers to transplant, the Coalition developed a survey of dialysis providers in the region. METHODS All dialysis units in the ESRD Network (n = 586) were sent a survey to be completed by the professional responsible for helping patients get transplants. RESULTS One staff member at almost all (n = 546) of the dialysis units in Network 6 completed the survey (93% response rate). Almost all respondents reported being very comfortable (51.47%) or comfortable (46.89%) discussing the KTx process with patients. Just over half (56%) of facilities reported discussing KTx as a treatment option with patients on an annual basis. Fewer than one quarter of respondents (19%) perceived that more than 50% of their patients were interested in kidney transplant, and most of the staff surveyed (68%) reported that <25% of their dialysis patients completed the evaluation process and been wait-listed for a kidney transplant. CONCLUSION The survey results provide insight into KTx referral practices in southeastern dialysis units that may be contributing to low KTx rates in this region.
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Affiliation(s)
- Teri Browne
- University of South Carolina, Columbia, SC, USA
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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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Martin DE, White SL. Financial Incentives for Living Kidney Donors: Are They Necessary? Am J Kidney Dis 2015; 66:389-95. [DOI: 10.1053/j.ajkd.2015.03.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 03/06/2015] [Indexed: 12/17/2022]
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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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Madhavan P, Jairath S, Sukumaran N, Sagar A, Molmenti E, Natarajan B, Basu A, Ali N, Bhaskaran M. Kidney transplant access in the southeast: middle view. Am J Transplant 2014; 14:2669-70. [PMID: 25219445 DOI: 10.1111/ajt.12980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- P Madhavan
- North Shore LIJ Health System, Renal Transplant Center, New York, NY
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Patzer RE, Gander J, Sauls L, Amamoo MA, Krisher J, Mulloy LL, Gibney E, Browne T, Plantinga L, Pastan SO. The RaDIANT community study protocol: community-based participatory research for reducing disparities in access to kidney transplantation. BMC Nephrol 2014; 15:171. [PMID: 25348614 PMCID: PMC4230631 DOI: 10.1186/1471-2369-15-171] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 09/23/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Southeastern United States has the lowest kidney transplant rates in the nation, and racial disparities in kidney transplant access are concentrated in this region. The Southeastern Kidney Transplant Coalition (SEKTC) of Georgia, North Carolina, and South Carolina is an academic and community partnership that was formed with the mission to improve access to kidney transplantation and reduce disparities among African American (AA) end stage renal disease (ESRD) patients in the Southeastern United States. METHODS/DESIGN We describe the community-based participatory research (CBPR) process utilized in planning the Reducing Disparities In Access to kidNey Transplantation (RaDIANT) Community Study, a trial developed by the SEKTC to reduce health disparities in access to kidney transplantation among AA ESRD patients in Georgia, the state with the lowest kidney transplant rates in the nation. The SEKTC Coalition conducted a needs assessment of the ESRD population in the Southeast and used results to develop a multicomponent, dialysis facility-randomized, quality improvement intervention to improve transplant access among dialysis facilities in GA. A total of 134 dialysis facilities are randomized to receive either: (1) standard of care or "usual" transplant education, or (2) the multicomponent intervention consisting of transplant education and engagement activities targeting dialysis facility leadership, staff, and patients within dialysis facilities. The primary outcome is change in facility-level referral for kidney transplantation from baseline to 12 months; the secondary outcome is reduction in racial disparity in transplant referral. DISCUSSION The RaDIANT Community Study aims to improve equity in access to kidney transplantation for ESRD patients in the Southeast. TRIAL REGISTRATION Clinicaltrials.gov number NCT02092727.
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Affiliation(s)
- Rachel E Patzer
- />Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA USA
- />Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA USA
- />Emory Transplant Center, Atlanta, GA USA
| | - Jennifer Gander
- />Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA USA
| | | | | | | | - Laura L Mulloy
- />Department of Medicine, Section of Nephrology, Hypertension, and Transplant Medicine, Georgia Regents University, Augusta, GA USA
| | - Eric Gibney
- />Piedmont Transplant Institute, Atlanta, GA USA
| | - Teri Browne
- />College of Social Work, University of South Carolina, Columbia, SC USA
| | - Laura Plantinga
- />Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Stephen O Pastan
- />Emory Transplant Center, Atlanta, GA USA
- />Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, GA USA
| | - on behalf of the Southeastern Kidney Transplant Coalition
- />Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA USA
- />Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA USA
- />Emory Transplant Center, Atlanta, GA USA
- />Southeastern Kidney Council, Inc, Raleigh, NC USA
- />Department of Medicine, Section of Nephrology, Hypertension, and Transplant Medicine, Georgia Regents University, Augusta, GA USA
- />Piedmont Transplant Institute, Atlanta, GA USA
- />College of Social Work, University of South Carolina, Columbia, SC USA
- />Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, GA USA
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Plantinga L, Pastan S, Kramer M, McClellan A, Krisher J, Patzer RE. Association of U.S. Dialysis facility neighborhood characteristics with facility-level kidney transplantation. Am J Nephrol 2014; 40:164-73. [PMID: 25196018 PMCID: PMC4175288 DOI: 10.1159/000365596] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 06/29/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Improving access to optimal healthcare may depend on the attributes of neighborhoods where patients receive healthcare services. We investigated whether the characteristics of dialysis facility neighborhoods--where most patients with end-stage renal disease are treated--were associated with facility-level kidney transplantation. METHODS We examined the association between census tract (neighborhood)-level sociodemographic factors and facility-level kidney transplantation rate in 3,983 U.S. dialysis facilities where kidney transplantation rates were high. Number of kidney transplants and total person-years contributed at the facility level in 2007-2010 were obtained from the Dialysis Facility Report and linked to the census tract data on sociodemographic characteristics from the American Community Survey 2006-2010 by dialysis facility location. We used multivariable Poisson models with generalized estimating equations to estimate the link between the neighborhood characteristics and transplant incidence. RESULTS Dialysis facilities in the United States were located in neighborhoods with substantially greater proportions of black and poor residents, relative to the national average. Most facility neighborhood characteristics were associated with transplant, with incidence rate ratios (95% CI) for standardized increments (in percentage) of neighborhood exposures of: living in poverty, 0.88 (0.84-0.92), black race, 0.83 (0.78-0.89); high school graduates, 1.22 (1.17-1.26); and unemployed, 0.90 (0.85-0.95). CONCLUSION Dialysis facility neighborhood characteristics may be modestly associated with facility rates of kidney transplantation. The success of dialysis facility interventions to improve access to kidney transplantation may partially depend on reducing neighborhood-level barriers.
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Affiliation(s)
- Laura Plantinga
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
- Laney Graduate School, Emory University, Atlanta, GA
| | - Stephen Pastan
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Emory Transplant Center, Emory Healthcare, Atlanta, GA
| | - Michael Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Ann McClellan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Jenna Krisher
- Southeastern Kidney Council, ESRD Network 6, Raleigh, NC
| | - Rachel E. Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
- Emory Transplant Center, Emory Healthcare, Atlanta, GA
- Emory University School of Medicine, Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA
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Srinivas TR. Kidney transplant access in the Southeastern United States: the need for a top-down transformation. Am J Transplant 2014; 14:1506-11. [PMID: 24891111 DOI: 10.1111/ajt.12747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 03/03/2014] [Accepted: 03/03/2014] [Indexed: 01/25/2023]
Abstract
End-stage renal disease (ESRD) and poverty are highly prevalent conditions in the Southeastern United States. The American Southeast also has some of the lowest attainments of health status among its constituents. Transplantation rates are particularly low in the Southeast compared with other regions of the United States. These low kidney transplantation rates in the Southeast likely reflect poor access to medical care. This disproportionate lack of access to medical care among ESRD patients in the Southeast reflects the convergence and interaction of socioeconomic and biologic forces at the patient level interacting with the financial and organizational structure of the health-care system. Improving kidney transplant access in the Southeast will take disruptive political, financial and health system changes whose scope transcends transplant centers and dialysis units.
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Affiliation(s)
- T R Srinivas
- Transplant Nephrology Section, Division of Nephrology, Medical University of South Carolina, Charleston, SC
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