Effectiveness of a culturally competent care intervention in reducing disparities in Hispanic live donor kidney transplantation: A hybrid trial

A Transplant-Inclusive Value-Based Kidney Care Payment Model

In the United States, kidney care payment models are migrating toward value-based care (VBC) models incentivizing quality of care at lower cost. Current kidney VBC models will continue through 2026. We propose a future transplant-inclusive VBC (TIVBC) model designed to supplement current models focusing on patients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD). The proposed TIVBC is structured as an episode-of-care model with risk-based reimbursement for "referral/evaluation/waitlisting" (REW, referencing kidney transplantation), "primary hospitalization to 180 days posttransplant," and "long-term graft survival." Challenges around organ acquisition costs, adjustments to quality metrics, and potential criticisms of the proposed model are discussed. We propose next steps in risk-adjustment and cost-prediction to develop as an end-to-end, TIVBC model.

Effect of a Hispanic outreach program on referral and liver transplantation volume at a single center

BACKGROUND

Although Hispanic patients have high rates of end-stage liver disease and liver cancer, for which liver transplantation (LT) offers the best long-term outcomes, they are less likely to receive LT. Studies of end-stage renal disease patients and kidney transplant candidates have shown that targeted, culturally relevant interventions can increase the likelihood of Hispanic patients receiving kidney transplant. However, similar interventions remain largely unstudied in potential LT candidates.

METHODS

Referrals to a single center in Texas with a large Hispanic patient population were compared before (01/2018-12/2019) and after (7/2021-6/2023) the implementation of a targeted outreach program. Patient progress toward LT, reasons for ineligibility, and differences in insurance were examined between the two eras.

RESULTS

A greater proportion of Hispanic patients were referred for LT after the implementation of the outreach program (23.2% vs 26.2%, p = 0.004). Comparing the pre-outreach era to the post-outreach era, more Hispanic patients achieved waitlisting status (61 vs 78, respectively) and received a LT (971 vs 82, respectively). However, the proportion of Hispanic patients undergoing LT dropped from 30.2% to 20.3%. In the post-outreach era, half of the Hispanic patients were unable to get LT for financial reasons (112, 50.5%).

CONCLUSIONS

A targeted outreach program for Hispanic patients with end-stage liver disease effectively increased the total number of Hispanic LT referrals and recipients. However, many of the patients who were referred were ineligible for LT, most frequently for financial reasons. These results highlight the need for additional research into the most effective ways to ameliorate financial barriers to LT in this high-need community.

Use of Federal Reimbursement for Living Donor Costs by Racial and Ethnic Minorities: Implications for Disparities in Access to Living Donor Transplantation

BACKGROUND

Minority race, ethnicity, and financial barriers are associated with lower rates of living donor (LD) kidney transplantation (LDKT). Financial reimbursement for LD costs may impact social determinants of health and, therefore, impact disparities in access to LDKT.

METHODS

Among US LDKTs, we studied associations between racial and ethnic minority status and utilization of the National Living Donor Assistance Center (NLDAC), a means-tested reimbursement program for nonmedical LD costs. We analyzed demographic, clinical, income, and survey data from NLDAC and the Scientific Registry of Transplant Recipients (January 1, 2011, to December 31, 2022) to identify predictors of NLDAC utilization.

RESULTS

Among 70 069 US LDKTs, 6093 NLDAC applicants were identified (9% of US LDKTs). Racial and ethnic minorities were over-represented in NLDAC-supported LDKTs compared with non-NLDAC US LDKTs (Black donors 12% versus 9%; Black recipients 15% versus 12%; Hispanic donors 21% versus 14%; Hispanic recipients 23% versus 15%; all P < 0.001). Among preemptive transplants, use of NLDAC by donors to Hispanic recipients (11%) was nearly twice as high as that of non-Hispanic recipients (6%) (P < 0.001). At time of NLDAC application, 72% stated NLDAC "will make it possible" to donate; higher proportions of minority applicants agreed (Black 80%, White 70%, P < 0.001; Hispanic 79%, non-Hispanic 70%, P < 0.001). Racial and ethnic minority-concordant transplants were significantly more likely to use NLDAC (donor/recipient: Black/Black risk-adjusted odds ratio [OR], 1.85, other/other OR 2.59, Hispanic/Hispanic OR 1.53; all P < 0.05).

CONCLUSIONS

Reduction of LD financial barriers may increase access to LDKT, particularly in racial and ethnic minority communities.

Engineering Equity Into the Promise of Xenotransplantation

Two of the greatest challenges facing kidney transplantation are the lack of donated organs and inequities in who receives a transplant. Xenotransplantation holds promise as a treatment approach that could solve the supply problem. Major advances in gene-editing procedures have enabled several companies to raise genetically engineered pigs for organ donation. These porcine organs lack antigens and have other modifications that should reduce the probability of immunological rejection when transplanted into humans. The US Food and Drug Administration and transplantation leaders are starting to chart a path to test xenotransplants in clinical trials and later integrate them into routine clinical care. Here we provide a framework that industry, regulatory authorities, payers, transplantation professionals, and patient groups can implement to promote equity during every stage in this process. We also call for immediate action. Companies developing xenotransplant technology should assemble patient advocacy boards to bring the concerns of individuals with end-stage kidney disease to the forefront. For trials, xenotransplantation companies should partner with transplant programs with substantial patient populations of racial and ethnic minority groups and that have reciprocal relationships with those communities. Those companies and transplant programs should reach out now to those communities to inform them about xenotransplantation and try to address their concerns. These actions have the potential to make these communities full partners in the promise of xenotransplantation.

Disparities Persist Among Hispanic Patients: Completing Evaluation, Waitlisting, and Receiving a Kidney Transplant

Background

Hispanic patients receive disproportionately fewer kidney transplants (KT) than non-Hispanic White (NHW) patients. In this observational study, we evaluated disparities in completing evaluation steps to KT among Hispanic patients.

Methods

Using medical records of Hispanic and NHW patients initiating evaluation at 4 transplant centers from January 2011 to March 2020, we performed sequential Cox models to compare Hispanic versus NHW patients reaching each step of the evaluation process until receiving a KT.

Results

Among all 5197 patients (Hispanic n = 2473; NHW n = 2724) initiating evaluation, Hispanic patients had 8% lower risk to be approved by the kidney pancreas (KP) committee than NHW patients (adjusted hazard ratio [aHR], 0.92; 95% confidence intervals (CI), 0.86-0.98; P = 0.015). Among 3492 patients approved by the KP committee, Hispanic patients had 13% lower risk to be waitlisted than NHW patients (aHR, 0.87; 95% CI, 0.81-0.94; P = 0.004). Among 3382 patients who were waitlisted, Hispanic patients had 11% lower risk than NHW patients to receive KT (aHR, 0.89; 95% CI, 0.81-0.97; P = 0.011). Among all patients initiating evaluation, Hispanic patients had a 16% lower risk than NHW patients to reach KT (aHR, 0.84; 95% CI, 0.76-0.92; P = 0.0002).

Conclusions

Our study found that disproportionately fewer Hispanic patients were approved by the KP committee, were waitlisted, and received a KT, particularly a living donor kidney transplant, than NHW patients. Closer oversight of the evaluation process may help patients overcome challenges in access to KT.

Racial Equity in Living Donor Kidney Transplant Centers, 2008-2018

Importance

It is unclear whether center-level factors are associated with racial equity in living donor kidney transplant (LDKT).

Objective

To evaluate center-level factors and racial equity in LDKT during an 11-year time period.

Design, Setting, and Participants

A retrospective cohort longitudinal study was completed in February 2023, of US transplant centers with at least 12 annual LDKTs from January 1, 2008, to December 31, 2018, identified in the Health Resources Services Administration database and linked to the US Renal Data System and the Scientific Registry of Transplant Recipients.

Main Outcomes and Measures

Observed and model-based estimated Black-White mean LDKT rate ratios (RRs), where an RR of 1 indicates racial equity and values less than 1 indicate a lower rate of LDKT of Black patients compared with White patients. Estimated yearly best-case center-specific LDKT RRs between Black and White individuals, where modifiable center characteristics were set to values that would facilitate access to LDKT.

Results

The final cohorts of patients included 394 625 waitlisted adults, of whom 33.1% were Black and 66.9% were White, and 57 222 adult LDKT recipients, of whom 14.1% were Black and 85.9% were White. Among 89 transplant centers, estimated yearly center-level RRs between Black and White individuals accounting for center and population characteristics ranged from 0.0557 in 2008 to 0.771 in 2018. The yearly median RRs ranged from 0.216 in 2016 to 0.285 in 2010. Model-based estimations for the hypothetical best-case scenario resulted in little change in the minimum RR (from 0.0557 to 0.0549), but a greater positive shift in the maximum RR from 0.771 to 0.895. Relative to the observed 582 LDKT in Black patients and 3837 in White patients, the 2018 hypothetical model estimated an increase of 423 (a 72.7% increase) LDKTs for Black patients and of 1838 (a 47.9% increase) LDKTs for White patients.

Conclusions and Relevance

In this cohort study of patients with kidney failure, no substantial improvement occurred over time either in the observed or the covariate-adjusted estimated RRs. Under the best-case hypothetical estimations, modifying centers' participation in the paired exchange and voucher programs and increased access to public insurance may contribute to improved racial equity in LDKT. Additional work is needed to identify center-level and program-specific strategies to improve racial equity in access to LDKT.

Race, Age, and Kidney Transplant Waitlisting Among Patients Receiving Incident Dialysis in the United States

Rationale & Objective

Patients with kidney failure from racial and ethnic minority groups and older patients have reduced access to the transplant waitlist relative to White and younger patients. Although racial disparities in the waitlisting group have declined after the 2014 kidney allocation system change, whether there is intersectionality of race and age in waitlisting access is unknown.

Study Design

Retrospective cohort study.

Setting & Participants

439,455 non-Hispanic White and non-Hispanic Black US adults initiating dialysis between 2015 and 2019 were identified from the United States Renal Data System, and followed through 2020.

Exposures

Patient race and ethnicity (non-Hispanic White and non-Hispanic Black) and age group (18-29, 30-49, 50-64, and 65-80 years).

Outcomes

Placement on the United Network for Organ Sharing deceased donor waitlist.

Analytical Approach

Age- and race-stratified waitlisting rates were compared. Multivariable Cox proportional hazards models, censored for death, examined the association between race and waitlisting, and included interaction term for race and age.

Results

Over a median follow-up period of 1 year, the proportion of non-Hispanic White and non-Hispanic Black patients waitlisted was 20.7% and 20.5%, respectively. In multivariable models, non-Hispanic Black patients were 14% less likely to be waitlisted (aHR, 0.86, 95% CI, 0.77-0.95). Relative differences between non-Hispanic Black and non-Hispanic White patients were different by age group. Non-Hispanic Black patients were 27%, 12%, and 20% less likely to be waitlisted than non-Hispanic White patients for ages 18-29 years (aHR, 0.73; 95% CI, 0.61-0.86), 50-64 (aHR, 0.88; 95% CI, 0.80-0.98), and 65-80 years (aHR, 0.80; 95% CI, 0.71-0.90), respectively, but differences were attenuated among patients aged 30-49 years (aHR, 0.89; 95% CI, 0.77-1.02).

Limitations

Race and ethnicity data is physician reported, residual confounding, and analysis is limited to non-Hispanic White and non-Hispanic Black patients.

Conclusions

Racial disparities in waitlisting exist between non-Hispanic Black and non-Hispanic White individuals and are most pronounced among younger patients with kidney failure. Results suggest that interventions to address inequalities in waitlisting may need to be targeted to younger patients with kidney failure.

Plain-Language Summary

Research has shown that patients from racial and ethnic minority groups and older patients have reduced access to transplant waitlisting relative to White and younger patients; nevertheless, how age impacts racial disparities in waitlisting is unknown. We compared waitlisting between non-Hispanic Black and non-Hispanic White patients with incident kidney failure, within age strata, using registry data for 439,455 US adults starting dialysis (18-80 years) during 2015-2019. Overall, non-Hispanic Black patients were less likely to be waitlisted and relative differences between the two racial groups differed by age. After adjusting for patient-level factors, the largest disparity in waitlisting was observed among adults aged 18-29 years. These results suggest that interventions should target younger adults to reduce disparities in access to kidney transplant waitlisting.

Breaking Barriers and Bridging Gaps: Advancing Diversity, Equity, and Inclusion in Kidney Transplant Care for Black and Hispanic Patients in the United States

Kidney transplantation offers better mortality and quality of life outcomes to patients with end-stage renal failure compared to dialysis. Specifically, living donor kidney transplantation is the best treatment for end-stage renal disease, since it offers the greatest survival benefit compared to deceased donor kidney transplant or dialysis. However, not all patients from all racial/ethnic backgrounds enjoy these benefits. While black and Hispanic patients bear the predominant disease burden within the United States, they represent less than half of all kidney transplants in the country. Other factors such as cultural barriers that proliferate myths about transplant, financial costs that impede altruistic donation, and even biological predispositions create a complex maze and can also perpetuate care inaccessibility. Therefore, blanket efforts to increase the overall donation pool may not extend access to vulnerable populations, who may require more targeted attention and interventions. This review uses US kidney transplantation data to substantiate accessibility differences amongst racial minorities as well as provides examples of successful institutional and national systemic level changes that have improved transplantation outcomes for all.

Racial and ethnic disparities in psychosocial evaluation and liver transplant waitlisting

Health disparities have been well-described in all stages of the liver transplantation (LT) process. Using data from psychosocial evaluations and the Stanford Integrated Psychosocial Assessment, our objective was to investigate potential racial and ethnic inequities in overall LT waitlisting and not waitlisting for medical or psychosocial reasons. In a cohort of 2271 candidates evaluated for LT from 2014 to 2021 and with 1-8 years of follow-up, no significant associations were noted between race/ethnicity and overall waitlisting and not waitlisting for medical reasons. However, compared with White race, Black race (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.07-2.56) and Hispanic/Latinx ethnicity (OR, 2.10; 95% CI, 1.16-3.78) were associated with not waitlisting for psychosocial reasons. After adjusting for sociodemographic variables, the relationship persisted in both populations: Black (OR, 1.95; 95% CI, 1.12-3.38) and Hispanic/Latinx (OR, 2.29; 95% CI, 1.08-4.86) (reference group, White). High-risk Stanford Integrated Psychosocial Assessment scores were more prevalent in Black and Hispanic/Latinx patients, likely reflecting upstream factors and structural racism. Health systems and LT centers should design programs to combat these disparities and improve equity in access to LT.

Adaptive Content Tuning of Social Network Digital Health Interventions Using Control Systems Engineering for Precision Public Health: Cluster Randomized Controlled Trial

BACKGROUND

Social media has emerged as an effective tool to mitigate preventable and costly health issues with social network interventions (SNIs), but a precision public health approach is still lacking to improve health equity and account for population disparities.

OBJECTIVE

This study aimed to (1) develop an SNI framework for precision public health using control systems engineering to improve the delivery of digital educational interventions for health behavior change and (2) validate the SNI framework to increase organ donation awareness in California, taking into account underlying population disparities.

METHODS

This study developed and tested an SNI framework that uses publicly available data at the ZIP Code Tabulation Area (ZCTA) level to uncover demographic environments using clustering analysis, which is then used to guide digital health interventions using the Meta business platform. The SNI delivered 5 tailored organ donation-related educational contents through Facebook to 4 distinct demographic environments uncovered in California with and without an Adaptive Content Tuning (ACT) mechanism, a novel application of the Proportional Integral Derivative (PID) method, in a cluster randomized trial (CRT) over a 3-month period. The daily number of impressions (ie, exposure to educational content) and clicks (ie, engagement) were measured as a surrogate marker of awareness. A stratified analysis per demographic environment was conducted.

RESULTS

Four main clusters with distinctive sociodemographic characteristics were identified for the state of California. The ACT mechanism significantly increased the overall click rate per 1000 impressions (β=.2187; P<.001), with the highest effect on cluster 1 (β=.3683; P<.001) and the lowest effect on cluster 4 (β=.0936; P=.053). Cluster 1 is mainly composed of a population that is more likely to be rural, White, and have a higher rate of Medicare beneficiaries, while cluster 4 is more likely to be urban, Hispanic, and African American, with a high employment rate without high income and a higher proportion of Medicaid beneficiaries.

CONCLUSIONS

The proposed SNI framework, with its ACT mechanism, learns and delivers, in real time, for each distinct subpopulation, the most tailored educational content and establishes a new standard for precision public health to design novel health interventions with the use of social media, automation, and machine learning in a form that is efficient and equitable.

TRIAL REGISTRATION

ClinicalTrials.gov NTC04850287; https://clinicaltrials.gov/ct2/show/NCT04850287.

Financial Impact of a Culturally Sensitive Hispanic Kidney Transplant Program on Increasing Living Donation

BACKGROUND

In the United States, Hispanic/Latinx patients receive disproportionately fewer living donor kidney transplants (LDKTs) than non-Hispanic White patients. Northwestern Medicine's culturally targeted Hispanic Kidney Transplant Program (HKTP) was found to increase LDKTs in Hispanic patients at 1 of 2 transplant programs with greater implementation fidelity.

METHODS

We conducted a budget impact analysis to evaluate HKTP's impact on program financial profiles from changes in volume of LDKTs and deceased donor kidney transplants (DDKTs) in 2017 to 2019. We estimated HKTP programmatic costs, and kidney transplant (KT) program costs and revenues. We forecasted transplant volumes, HKTP programmatic costs, and KT program costs and revenues for 2022-2024.

RESULTS

At both programs, HKTP programmatic costs had <1% impact on total KT program costs, and HKTP programmatic costs comprised <1% of total KT program revenues in 2017-2019. In particular, the total volume of Hispanic KTs and HKTP LDKTs increased at both sites. Annual KT program revenues of HKTP LDKTs and DDKTs increased by 226.9% at site A and by 1042.9% at site B when comparing 2019-2017. Forecasted HKTP LDKT volume showed an increase of 36.4% (site A) and 33.3% (site B) with a subsequent increase in KT program revenues of 42.3% (site A) and 44.3% (site B) among HKTP LDKTs and DDKTs.

CONCLUSIONS

HKTP programmatic costs and KT evaluation costs are potentially recoverable by reimbursement of organ acquisition costs and offset by increases in total KT program revenues of LDKTs; transplant programs may find implementation of the HKTP financially manageable.

Addressing sex-based disparities in solid organ transplantation in the United States - a conference report

Solid organ transplantation provides the best treatment for end-stage organ failure, but significant sex-based disparities in transplant access exist. On June 25, 2021, a virtual multidisciplinary conference was convened to address sex-based disparities in transplantation. Common themes contributing to sex-based disparities were noted across kidney, liver, heart, and lung transplantation, specifically the existence of barriers to referral and wait listing for women, the pitfalls of using serum creatinine, the issue of donor/recipient size mismatch, approaches to frailty and a higher prevalence of allosensitization among women. In addition, actionable solutions to improve access to transplantation were identified, including alterations to the current allocation system, surgical interventions on donor organs, and the incorporation of objective frailty metrics into the evaluation process. Key knowledge gaps and high-priority areas for future investigation were also discussed.

The ASCENT Intervention to Improve Access and Reduce Racial Inequalities in Kidney Waitlisting: A Randomized, Effectiveness-Implementation Trial

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.

Impact of having potential living donors on ethnic/racial disparities in access to kidney transplantation

Racial/ethnic disparities persist in patients' access to living donor kidney transplantation (LDKT). This study assessed the impact of having available potential living donors (PLDs) on candidates' receipt of a kidney transplant (KT) and LDKT at two KT programs. Using data from our clinical trial of waitlisted candidates (January 1, 2014-December 31, 2019), we evaluated Hispanic and Non-Hispanic White (NHW) KT candidates' number of PLDs. Multivariable logistic regression assessed the impact of PLDs on transplantation (KT vs. no KT; for KT recipients, LDKT vs. deceased donor KT). A total of 847 candidates were included, identifying as Hispanic (45.8%) or NHW (54.2%). For Site A, both Hispanic (adjusted OR = 2.26 [95% CI 1.13-4.53]) and NHW (OR = 2.42 [1.10-5.33]) candidates with PLDs completing the questionnaire were more likely to receive a KT. For Site B, candidates with PLDs were not significantly more likely to receive KT. Among KT recipients at both sites, Hispanic (Site A: OR = 21.22 [2.44-184.88]; Site B: OR = 25.54 [7.52-101.54]), and NHW (Site A: OR = 37.70 [6.59-215.67]; Site B: OR = 15.18 [5.64-40.85]) recipients with PLD(s) were significantly more likely to receive a LDKT. Our findings suggest that PLDs increased candidates' likelihood of KT receipt, particularly LDKT. Transplant programs should help candidates identify PLDs early in transplant evaluation.

Examining post-donation outcomes in Hispanic/Latinx living kidney donors in the United States: A systematic review

We conducted a systematic review to assess outcomes in Hispanic donors and explore how Hispanic ethnicity was characterized. We searched PubMed, EMBASE, and Scopus through October 2021. Two reviewers independently screened study titles, abstracts, and full texts; they also qualitatively synthesized results and independently assessed quality of included studies. Eighteen studies met our inclusion criteria. Study sample sizes ranged from 4007 to 143,750 donors and mean age ranged from 37 to 54 years. Maximum follow-up time of studies varied from a perioperative donor nephrectomy period to 30 years post-donation. Hispanic donors ranged between 6% and 21% of the donor populations across studies. Most studies reported Hispanic ethnicity under race or a combined race and ethnicity category. Compared to non-Hispanic White donors, Hispanic donors were not at increased risk for post-donation mortality, end-stage kidney disease, cardiovascular disease, non-pregnancy-related hospitalizations, or overall perioperative surgical complications. Compared to non-Hispanic White donors, most studies showed Hispanic donors were at higher risk for diabetes mellitus following nephrectomy; however, mixed findings were seen regarding the risk for post-donation chronic kidney disease and hypertension. Future studies should evaluate cultural, socioeconomic, and geographic differences within the heterogeneous Hispanic donor population, which may further explain variation in health outcomes.

The Kidney Transplant Equity Index: Improving Racial and Ethnic Minority Access to Transplantation

OBJECTIVES

To develop a scalable metric which quantifies kidney transplant (KT) centers' performance providing equitable access to KT for minority patients, based on the individualized pre-listing prevalence of End-Stage Renal Disease (ESRD).

SUMMARY BACKGROUND DATA

Racial and ethnic disparities for access to transplant in patients with ESRD are well described; however, variation in care among KT centers remains unknown. Furthermore, no mechanism exists that quantifies how well a KT center provides equitable access to KT for minority patients with ESRD.

METHODS

From 2013-2018, custom datasets from the United States Renal Data System and United Network for Organ Sharing were merged to calculate the Kidney Transplant Equity Index (KTEI), defined as: the number of minority patients transplanted at a center relative to the prevalence of minority patients with ESRD in each center's health service area. Markers of socioeconomic status (SES) and recipient outcomes were compared between high and low KTEI centers.

RESULTS

249 transplant centers performed 111,959 KTs relative to 475,914 non-transplanted patients with ESRD. High KTEI centers performed more KTs for Black (105.5 vs. 24, P<0.001), Hispanic (55.5 vs. 7, P<0.001), and American Indian (1.0 vs. 0.0, P<0.001) patients than low KTEI centers. In addition, high KTEI centers transplanted more patients with higher unemployment (52 vs. 44, P<0.001), worse social deprivation (53 vs. 46, P<0.001), and lower educational attainment (52 vs. 43, P<0.001). While providing increased access to transplant for minority and low SES populations, high KTEI centers had improved patient survival (HR: 0.86, 95% CI: 0.77-0.95).

CONCLUSIONS

The KTEI is the first metric to quantify minority access to KT incorporating the pre-listing ESRD prevalence individualized to transplant centers. KTEIs uncover significant national variation in transplant practices and identify highly equitable centers. This novel metric should be used to disseminate best practices for minority and low socioeconomic patients with ESRD.

Implementation and modification of an organizational-level intervention: a prospective analysis

Background

Modifications to interventions can jeopardize intervention outcomes. Pre-existing perceived barriers and facilitators to the intervention arising in the implementation preparation phase may help explain why modifications to the intervention may occur during the implementation phase. This two-site comparative case study describes modifications made to a complex organizational-level intervention and examines how known implementation science factors may have enabled such changes to occur.

Methods

Northwestern Medicine’s^TM Hispanic Kidney Transplant Program (HKTP) is a culturally competent transplant center-based intervention designed to reduce disparities in living donor kidney transplantation among Hispanics. In-depth qualitative interviews and discussions were longitudinally conducted with transplant stakeholders (i.e., physicians, administrators, clinicians) at two kidney transplant programs with large Hispanic populations during implementation preparation and implementation phases. The Consolidated Framework for Implementation Research (CFIR) guided interview design and qualitative analysis, and Stirman’s Framework for Reporting Adaptations and Modifications-Expanded (FRAME) guided modification classification.

Results

Across sites, 57 stakeholders participated in an interview, group discussion, and/or learning collaborative discussion. Site-B made more modifications than Site-A (n = 29 versus n = 18). Sites differed in the proportions of delaying/skipping (Site-A 50% versus Site-B 28%) and adding (Site-A 11% versus Site-B 28%) but had comparable substituting (Site-A 17% versus Site-B 17%) and tweaking (Site-A 17% versus Site-B 14%) modification types. Across sites, the transplant team consistently initiated the most modifications (Site-A 66%; Site-B 62%). While individuals initiated slightly more modifications at Site-B (21% versus Site-A 17%), institutions instigated proportionately slightly more modifications at Site-A (17% versus Site-B 10%). CFIR inner setting factors (i.e., structural characteristics, culture, available resources, implementation climate) that prominently emerged during the implementation preparation phase explained similarities and differences in sites’ modification numbers, types, and agents in the implementation phase.

Conclusion

Organizations implementing a culturally competent care intervention made modifications. CFIR inner setting factors emerging in the implementation preparation phase largely explained similarities and differences in study sites’ modifications. Identifying factors contributing to modifications may help institutions become better prepared to implement an intervention by addressing known factors in advance, which may foster greater fidelity leading to desired outcomes.

Trial registration

ClinicalTrials.govNCT03276390. We registered the study retrospectively on 9-7-17.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00296-0.

Overview of pediatric kidney transplantation

Kidney transplantation is the treatment of choice for pediatric patients with end-stage kidney disease. Unlike adult recipients undergoing transplantation, special considerations must be taken when transplanting children based on the underlying etiology of kidney disease, previous surgical procedures, anatomical limitations and necessary technical adjustments. Additionally, the choice of donor must be measured to ensure optimal graft survival given a longer post-transplant life expectancy. Those topics as well as frequently encountered postoperative complications are also discussed in this publication.

Sustainment of a Complex Culturally Competent Care Intervention for Hispanic Living Donor Kidney Transplantation: A Longitudinal Analysis of Adaptations

Introduction:

Sustainment refers to continued intervention delivery over time, while continuing to produce intended outcomes, often with ongoing adaptations, which are purposeful changes to the design or delivery of an intervention to improve its fit or effectiveness. The Hispanic Kidney Transplant Program (HKTP), a complex, culturally competent intervention, was implemented in two transplant programs to reduce disparities in Hispanic/Latinx living donor kidney transplant rates. This study longitudinally examined the influence of adaptations on HKTP sustainment.

Methods:

Qualitative interviews, learning collaborative calls, and telephone meetings with physicians, administrators, and staff (n = 55) were conducted over three years of implementation to identify HKTP adaptations. The Framework for Reporting Adaptations and Modifications-Expanded was used to classify adaptation types and frequency, which were compared across sites over time.

Results:

Across sites, more adaptations were made in the first year (n = 47), then fell and plateaued in the two remaining years (n = 35). Adaptations at Site-A were consistent across years (2017: n = 18, 2018: n = 17, 2019: n = 14), while Site-B made considerably fewer adaptations after the first year (2017: n = 29, 2018: n = 18, 2019: n = 21). Both sites proportionally made mostly skipping (32%), adding (20%), tweaking (20%), and substituting (16%) adaptation types. Skipping- and substituting-type adaptations were made due to institutional structural characteristics and lack of available resources, respectively. However, Site-A’s greater proportion of skipping-type adaptations was attributed to greater system complexity, and Site-B’s greater proportion of adding-type adaptation was attributed to the egalitarian team-based culture.

Conclusion:

Our findings can help prepare implementers to expect certain context-specific adaptations and preemptively avoid those that hinder sustainment.