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Jesse MT. Education Is Necessary but not Sufficient for Navigating Evaluations for Transplantation. Prog Transplant 2024; 34:7-8. [PMID: 38713549 DOI: 10.1177/15269248241238853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2024]
Affiliation(s)
- Michelle T Jesse
- Transplant Institute, Henry Ford Health System, Detroit, MI, USA
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2
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Drewry KM, Buford J, Patzer RE. Access to the Transplant Waiting List: All-too-Familiar Inequities Even Among Younger and Healthier Candidates. Am J Kidney Dis 2024; 83:684-687. [PMID: 38154783 DOI: 10.1053/j.ajkd.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/13/2023] [Accepted: 12/19/2023] [Indexed: 12/30/2023]
Affiliation(s)
- Kelsey M Drewry
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Regenstrief Institute, Center for Health Services Research, Indianapolis, Indiana
| | - Jade Buford
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Rachel E Patzer
- Division of Transplant, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Regenstrief Institute, Center for Health Services Research, Indianapolis, Indiana.
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3
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Nishio Lucar AG, Patel A, Mehta S, Yadav A, Doshi M, Urbanski MA, Concepcion BP, Singh N, Sanders ML, Basu A, Harding JL, Rossi A, Adebiyi OO, Samaniego-Picota M, Woodside KJ, Parsons RF. Expanding the access to kidney transplantation: Strategies for kidney transplant programs. Clin Transplant 2024; 38:e15315. [PMID: 38686443 DOI: 10.1111/ctr.15315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/05/2024] [Accepted: 03/28/2024] [Indexed: 05/02/2024]
Abstract
Kidney transplantation is the most successful kidney replacement therapy available, resulting in improved recipient survival and societal cost savings. Yet, nearly 70 years after the first successful kidney transplant, there are still numerous barriers and untapped opportunities that constrain the access to transplant. The literature describing these barriers is extensive, but the practices and processes to solve them are less clear. Solutions must be multidisciplinary and be the product of strong partnerships among patients, their networks, health care providers, and transplant programs. Transparency in the referral, evaluation, and listing process as well as organ selection are paramount to build such partnerships. Providing early culturally congruent and patient-centered education as well as maximizing the use of local resources to facilitate the transplant work up should be prioritized. Every opportunity to facilitate pre-emptive kidney transplantation and living donation must be taken. Promoting the use of telemedicine and kidney paired donation as standards of care can positively impact the work up completion and maximize the chances of a living donor kidney transplant.
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Affiliation(s)
- Angie G Nishio Lucar
- Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
| | - Ankita Patel
- Recanati-Miller Transplantation Institute, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shikha Mehta
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Anju Yadav
- Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mona Doshi
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Megan A Urbanski
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Neeraj Singh
- Willis Knighton Health System, Shreveport, Louisiana, USA
| | - M Lee Sanders
- Department of Internal Medicine, Division of Nephrology, Organ Transplant Center, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Arpita Basu
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jessica L Harding
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ana Rossi
- Piedmont Transplant Institute, Atlanta, Georgia, USA
| | - Oluwafisayo O Adebiyi
- Department of Medicine, Indiana University Health Hospital, Indianapolis, Indiana, USA
| | | | | | - Ronald F Parsons
- Department of Surgery, University of Pennsylvannia, Philadelphia, Pennsylvania, USA
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4
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Reed RD, Locke JE. Mitigating Health Disparities in Transplantation Requires Equity, Not Equality. Transplantation 2024; 108:100-114. [PMID: 38098158 PMCID: PMC10796154 DOI: 10.1097/tp.0000000000004630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Despite decades of research and evidence-based mitigation strategies, disparities in access to transplantation persist for all organ types and in all stages of the transplant process. Although some strategies have shown promise for alleviating disparities, others have fallen short of the equity goal by providing the same tools and resources to all rather than tailoring the tools and resources to one's circumstances. Innovative solutions that engage all stakeholders are needed to achieve equity regardless of race, sex, age, socioeconomic status, or geography. Mitigation of disparities is paramount to ensure fair and equitable access for those with end-stage disease and to preserve the trust of the public, upon whom we rely for their willingness to donate organs. In this overview, we present a summary of recent literature demonstrating persistent disparities by stage in the transplant process, along with policies and interventions that have been implemented to combat these disparities and hypotheses for why some strategies have been more effective than others. We conclude with future directions that have been proposed by experts in the field and how these suggested strategies may help us finally arrive at equity in transplantation.
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Affiliation(s)
- Rhiannon D. Reed
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E. Locke
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL
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5
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Garg AX, Yohanna S, Naylor KL, McKenzie SQ, Mucsi I, Dixon SN, Luo B, Sontrop JM, Beaucage M, Belenko D, Coghlan C, Cooper R, Elliott L, Getchell L, Heale E, Ki V, Nesrallah G, Patzer RE, Presseau J, Reich M, Treleaven D, Wang C, Waterman AD, Zaltzman J, Blake PG. Effect of a Novel Multicomponent Intervention to Improve Patient Access to Kidney Transplant and Living Kidney Donation: The EnAKT LKD Cluster Randomized Clinical Trial. JAMA Intern Med 2023; 183:1366-1375. [PMID: 37922156 PMCID: PMC10696487 DOI: 10.1001/jamainternmed.2023.5802] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/30/2023] [Indexed: 11/05/2023]
Abstract
Importance Patients with advanced chronic kidney disease (CKD) have the best chance for a longer and healthier life if they receive a kidney transplant. However, many barriers prevent patients from receiving a transplant. Objectives To evaluate the effect of a multicomponent intervention designed to target several barriers that prevent eligible patients from completing key steps toward receiving a kidney transplant. Design, Setting, and Participants This pragmatic, 2-arm, parallel-group, open-label, registry-based, superiority, cluster randomized clinical trial included all 26 CKD programs in Ontario, Canada, from November 1, 2017, to December 31, 2021. These programs provide care for patients with advanced CKD (patients approaching the need for dialysis or receiving maintenance dialysis). Interventions Using stratified, covariate-constrained randomization, allocation of the CKD programs at a 1:1 ratio was used to compare the multicomponent intervention vs usual care for 4.2 years. The intervention had 4 main components, (1) administrative support to establish local quality improvement teams; (2) transplant educational resources; (3) an initiative for transplant recipients and living donors to share stories and experiences; and (4) program-level performance reports and oversight by administrative leaders. Main Outcomes and Measures The primary outcome was the rate of steps completed toward receiving a kidney transplant. Each patient could complete up to 4 steps: step 1, referred to a transplant center for evaluation; step 2, had a potential living donor contact a transplant center for evaluation; step 3, added to the deceased donor waitlist; and step 4, received a transplant from a living or deceased donor. Results The 26 CKD programs (13 intervention, 13 usual care) during the trial period included 20 375 potentially transplant-eligible patients with advanced CKD (intervention group [n = 9780 patients], usual-care group [n = 10 595 patients]). Despite evidence of intervention uptake, the step completion rate did not significantly differ between the intervention vs usual-care groups: 5334 vs 5638 steps; 24.8 vs 24.1 steps per 100 patient-years; adjusted hazard ratio, 1.00 (95% CI, 0.87-1.15). Conclusions and Relevance This novel multicomponent intervention did not significantly increase the rate of completed steps toward receiving a kidney transplant. Improving access to transplantation remains a global priority that requires substantial effort. Trial Registration ClinicalTrials.gov Identifier: NCT03329521.
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Affiliation(s)
- Amit X. Garg
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- ICES, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Kidney Patient & Donor Alliance, Canada
- Transplant Ambassador Program, Ontario, Canada
| | - Seychelle Yohanna
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kyla L. Naylor
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- ICES, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Susan Q. McKenzie
- Kidney Patient & Donor Alliance, Canada
- Transplant Ambassador Program, Ontario, Canada
| | - Istvan Mucsi
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stephanie N. Dixon
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- ICES, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Bin Luo
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- ICES, Ontario, Canada
| | - Jessica M. Sontrop
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Mary Beaucage
- Patient Governance Circle, Indigenous Peoples Engagement and Research Council and Executive Committee, Can-Solve CKD, Vancouver, British Columbia, Canada
- Provincial Patient and Family Advisory Council, Ontario Renal Network, Toronto, Ontario, Canada
- Patient co-lead Theme 1–Improve a Culture of Donation, Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada
| | - Dmitri Belenko
- Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - Candice Coghlan
- Centre for Living Organ Donation, University Health Network, Toronto, Ontario, Canada
| | - Rebecca Cooper
- Ontario Renal Network, Toronto, Ontario, Canada
- Trillium Gift of Life Network, Ontario Health, Toronto, Ontario, Canada
| | - Lori Elliott
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
| | - Leah Getchell
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- Can-SOLVE CKD Network, Vancouver BC, Canada
| | - Esti Heale
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
| | - Vincent Ki
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
- Trillium Health Partners, Mississauga, Ontario, Canada
| | - Gihad Nesrallah
- Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Humber River Regional Hospital, Toronto, Ontario, Canada
| | - Rachel E. Patzer
- Regenstrief Institute, Indianapolis, Indiana
- Department of Surgery, Division of Transplantation, Indiana University School of Medicine, Indianapolis
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ontario, Canada
| | - Marian Reich
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-Solve CKD), Patient Council, Vancouver, British Columbia, Canada
| | - Darin Treleaven
- Trillium Gift of Life Network, Ontario Health, Toronto, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
| | - Carol Wang
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- Division of Nephrology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Research Methods, Evidence and Uptake, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Amy D. Waterman
- Department of Surgery and J.C. Walter Jr. Transplant Center, Houston Methodist Hospital, Houston, Texas
| | - Jeffrey Zaltzman
- Trillium Gift of Life Network, Ontario Health, Toronto, Ontario, Canada
- Division of Nephrology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Peter G. Blake
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
- Division of Nephrology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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6
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Buford J, Retzloff S, Wilk AS, McPherson L, Harding JL, Pastan SO, Patzer RE. Race, Age, and Kidney Transplant Waitlisting Among Patients Receiving Incident Dialysis in the United States. Kidney Med 2023; 5:100706. [PMID: 37753250 PMCID: PMC10518364 DOI: 10.1016/j.xkme.2023.100706] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
Abstract
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.
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Affiliation(s)
- Jade Buford
- Regenstrief Institute, Indianapolis, Indiana
| | - Samantha Retzloff
- HIV Surveillance Branch (HSB), Division of HIV Prevention (DHP), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adam S. Wilk
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Laura McPherson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Jessica L. Harding
- Department of Epidemiology, Rollins School of Public Health, Emory University, Emory University, Emory University School of Medicine, Atlanta, Georgia
- Division of Transplantation, Department of Surgery, Emory University, Emory University School of Medicine, Atlanta, Georgia
- Health Services Research Center, Emory University School of Medicine, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Stephen O. Pastan
- Department of Medicine, Renal Division, Emory University, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E. Patzer
- Regenstrief Institute, Indianapolis, Indiana
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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7
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Nonterah CW, Utsey SO, Gupta G, Wilkins S, Gardiner HM. A Nominal Group Technique Study of Patients Who Identify as Black or African American and Access to Renal Transplantation. Prog Transplant 2023; 33:141-149. [PMID: 36938608 DOI: 10.1177/15269248231164164] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Introduction: Completion of the renal transplant evaluation has been associated with several barriers for patients who identify as Black or African American. This study sought to prioritize barriers to and motivators of completing the renal transplant evaluation. Methods/Approach: Semi-structured interviews and focus groups with a nominal group technique were used to generate priority scores. Transplant professionals (N = 23) were recruited from 9 transplant centers in the Mid-Atlantic, Mid-Western, and Southeastern parts of the United States. Black or African American identifying renal patients (N = 30) diagnosed with end-stage kidney disease were recruited from 1 transplant center in the Mid-Atlantic region. Findings: Priority scores were created to assess the quantitative data of participant rankings of top barriers and motivators. The most significant barriers identified by both patients and transplant professionals comprised financial constraints, insurance issues, difficulty navigating the healthcare system, transportation difficulties, and multiple health problems. Facilitators consisted of family/social support, transplant education, patient navigators, comprehensive insurance, and physician repertoire and investment. A qualitative description of the ranked factors resulted in themes classified as intrapersonal, health, socioeconomic, transplant-specific healthcare, and general healthcare. Conclusion: These findings provided vital information to transplant centers nationwide about assessing the influences of renal transplant evaluation completion. Achieving equity in access to transplantation for Black or African American renal patients requires multilayered approaches.
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Affiliation(s)
- Camilla W Nonterah
- Department of Psychology, 6888University of Richmond, Richmond, VA, USA.,Department of Psychiatry, Virginia Commonwealth University, School of Medicine, Richmond, VA, USA
| | - Shawn O Utsey
- Department of Psychology, 6889Virginia Commonwealth University, Richmond, VA, USA
| | - Gaurav Gupta
- Department of Internal Medicine, Division of Nephrology, Virginia Commonwealth University, School of Medicine, Richmond, VA, USA
| | - Sawyer Wilkins
- Department of Psychology, 6889Virginia Commonwealth University, Richmond, VA, USA
| | - Heather M Gardiner
- Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, PA, USA
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8
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Scholes‐Robertson N, Howell M, Carter SA, Manera KE, Viecelli AK, Au E, Chong C, Matus‐Gonzalez A, van Zwieten A, Reidlinger D, Wright C, Owen K, Craig JC, Tong A. Perspectives of a proposed patient navigator programme for people with chronic kidney disease in rural communities: Report from national workshops. Nephrology (Carlton) 2022; 27:886-896. [PMID: 36056193 PMCID: PMC9826117 DOI: 10.1111/nep.14105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/21/2022] [Accepted: 08/26/2022] [Indexed: 01/11/2023]
Abstract
AIMS People who live in rural areas have reduced access to appropriate and timely healthcare, leading to poorer health outcomes than their metropolitan-based counterparts. The aims of the workshops were to ascertain participants' perspectives on barriers to access to dialysis and transplantation, to identify and prioritize the roles of a rural patient navigator, to discuss the acceptability and feasibility of implementing this role and identify possible outcomes that could be used to measure the success of the programme in a clinical trial. METHODS Rural patients (n = 19), their caregivers (n = 5) and health professionals (n = 18) from Australia participated in three workshops. We analysed the data using thematic analysis. RESULTS We identified four themes related to access to dialysis and transplantation: overwhelmed by separate and disconnected health systems, unprepared for emotional toll and isolation, lack of practical support and inability to develop trust and rapport. Four themes related to the role of the patient navigator programme: valuing lived experience, offering cultural expertise, requiring a conduit, and flexibility of the job description. The key roles prioritized by participants were psychological support and networking, provision/consolidation of education, and provision of practical support. CONCLUSION Rural patients, caregivers and health professionals believed that programmes that include navigators with lived experience of dialysis and kidney transplantation and cultural expertise, especially for Aboriginal Australians, may have the potential to improve patient experiences in accessing healthcare.
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Affiliation(s)
- Nicole Scholes‐Robertson
- Sydney School of Public HealthThe University of SydneyCamperdownNew South WalesAustralia,Centre for Kidney ResearchThe Children's Hospital at WestmeadWestmeadNew South WalesAustralia
| | - Martin Howell
- Sydney School of Public HealthThe University of SydneyCamperdownNew South WalesAustralia,Centre for Kidney ResearchThe Children's Hospital at WestmeadWestmeadNew South WalesAustralia
| | - Simon A. Carter
- Sydney School of Public HealthThe University of SydneyCamperdownNew South WalesAustralia,Centre for Kidney ResearchThe Children's Hospital at WestmeadWestmeadNew South WalesAustralia
| | - Karine E. Manera
- Sydney School of Public HealthThe University of SydneyCamperdownNew South WalesAustralia,Centre for Kidney ResearchThe Children's Hospital at WestmeadWestmeadNew South WalesAustralia
| | - Andrea K. Viecelli
- Australasian Kidney Trials NetworkThe University of QueenslandBrisbaneQueenslandAustralia
| | - Eric Au
- Sydney School of Public HealthThe University of SydneyCamperdownNew South WalesAustralia,Centre for Kidney ResearchThe Children's Hospital at WestmeadWestmeadNew South WalesAustralia
| | - Chanel Chong
- Sydney School of Public HealthThe University of SydneyCamperdownNew South WalesAustralia,Centre for Kidney ResearchThe Children's Hospital at WestmeadWestmeadNew South WalesAustralia
| | - Andrea Matus‐Gonzalez
- Sydney School of Public HealthThe University of SydneyCamperdownNew South WalesAustralia,Centre for Kidney ResearchThe Children's Hospital at WestmeadWestmeadNew South WalesAustralia
| | - Anita van Zwieten
- Sydney School of Public HealthThe University of SydneyCamperdownNew South WalesAustralia,Centre for Kidney ResearchThe Children's Hospital at WestmeadWestmeadNew South WalesAustralia
| | - Donna Reidlinger
- Australasian Kidney Trials NetworkThe University of QueenslandBrisbaneQueenslandAustralia
| | - Chad Wright
- Australasian Kidney Trials NetworkThe University of QueenslandBrisbaneQueenslandAustralia
| | - Kelli Owen
- Australia and New Zealand Dialysis and Transplant Registry, NIKTT (National Indigenous Kidney Transplant Taskforce)CNARTS (Central and Northern Adelaide Renal Transplant Service) SA Health and Medical Research Institute, University of AdelaideAdelaideSouth AustraliaAustralia
| | - Jonathan C. Craig
- College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
| | - Allison Tong
- Sydney School of Public HealthThe University of SydneyCamperdownNew South WalesAustralia,Centre for Kidney ResearchThe Children's Hospital at WestmeadWestmeadNew South WalesAustralia
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9
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Taha A, Iman Y, Hingwala J, Askin N, Mysore P, Rigatto C, Bohm C, Komenda P, Tangri N, Collister D. Patient Navigators for CKD and Kidney Failure: A Systematic Review. Kidney Med 2022; 4:100540. [PMID: 36185707 PMCID: PMC9516458 DOI: 10.1016/j.xkme.2022.100540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Rationale & Objective To what degree and how patient navigators improve clinical outcomes for patients with chronic kidney disease (CKD) and kidney failure is uncertain. We performed a systematic review to summarize patient navigator program design, evidence, and implementation in kidney disease. Study Design A search strategy was developed for randomized controlled trials and observational studies that evaluated the impact of navigators on outcomes in the setting of CKD and kidney failure. Articles were identified from various databases. Two reviewers independently screened the articles and identified those meeting the inclusion criteria. Setting & Participants Patients with CKD or kidney failure (in-center hemodialysis, peritoneal dialysis, home hemodialysis, or kidney transplantation). Selection Criteria for Studies Studies that compared patient navigators with a control, without limits on size, duration, setting, or language. Studies focusing solely on patient education were excluded. Data Extraction Data were abstracted from full texts and risk of bias was assessed. Analytical Approach No meta-analysis was performed. Results Of 3,371 citations, 17 articles met the inclusion criteria including 14 original studies. Navigators came from various healthcare backgrounds including nursing (n=6), social worker (n=2), medical interpreter (n=1), research (n=1), and also included kidney transplant recipients (n=2) and non-medical individuals (n=2). Navigators focused mostly on education (n=9) and support (n = 6). Navigators were used for patients with CKD (n=5), peritoneal dialysis (n=2), in-center hemodialysis (n=4), kidney transplantation (n=2), but not home hemodialysis. Navigators improved transplant workup and listing, peritoneal dialysis utilization, and patient knowledge. Limitations Many studies did not show benefits across other outcomes, were at a high risk of bias, and none reported cost-effectiveness or patient-reported experience measures. Conclusions Navigators improve some health outcomes for CKD but there was heterogeneity in their structure and function. High-quality randomized controlled trials are needed to evaluate navigator program efficacy and cost-effectiveness.
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10
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Flemming JA, Muaddi H, Djerboua M, Neves P, Sapisochin G, Selzner N. Association between social determinants of health and rates of liver transplantation in individuals with cirrhosis. Hepatology 2022; 76:1079-1089. [PMID: 35313040 DOI: 10.1002/hep.32469] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS This study evaluated the association between neighborhood-level social determinants of health (SDOH) and liver transplantation (LT) among patients with cirrhosis who have universal access to health care. APPROACH AND RESULTS This was a retrospective population-based cohort study from 2000-2019 using administrative health care data from Ontario, Canada. Adults aged 18-70 years with newly decompensated cirrhosis and/or HCC were identified using validated coding. The associations between five neighborhood level SDOH quintiles and LT were assessed with multivariate Fine-Gray competing risks regression to generate subdistribution HRs (sHRs) where death competes with LT. Overall, n = 38,719 individuals formed the cohort (median age 57 years, 67% male), and n = 2788 (7%) received LT after a median of 23 months (interquartile range 3-68). Due to an interaction, results were stratified by sex. After multivariable regression and comparing those in the lowest versus highest quintiles, individuals living in the most materially resource-deprived areas (female sHR, 0.61; 95% CI, 0.49-0.76; male sHR, 0.55; 95% CI, 0.48-0.64), most residentially unstable neighborhoods (female sHR, 0.61; 95% CI, 0.49-0.75; male sHR, 0.56; 95% CI, 0.49-0.65), and lowest-income neighborhoods (female sHR, 0.57; 95% CI, 0.46-0.7; male sHR, 0.58; 95% CI, 0.50-0.67) had ~40% reduced subhazard for LT (p < 0.01 for all). No associations were found between neighborhoods with the most diverse immigrant or racial minority populations or age and labor force quintiles and LT. CONCLUSIONS This information highlights an urgent need to evaluate how SDOH influence rates of LT, with the overarching goal to develop strategies to overcome inequalities.
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Affiliation(s)
- Jennifer A Flemming
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.,Public Health Sciences, Queen's University, Kingston, Ontario, Canada.,ICES Queen's, Kingston, Ontario, Canada
| | - Hala Muaddi
- Department of Surgery, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Paula Neves
- Center for Living Organ Donation, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- Department of Surgery, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada.,Ajmera Transplant Centre, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Nazia Selzner
- Ajmera Transplant Centre, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
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11
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Patzer RE, Adler JT, Harding JL, Huml A, Kim I, Ladin K, Martins PN, Mohan S, Ross-Driscoll K, Pastan SO. A Population Health Approach to Transplant Access: Challenging the Status Quo. Am J Kidney Dis 2022; 80:406-415. [PMID: 35227824 DOI: 10.1053/j.ajkd.2022.01.422] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/09/2022] [Indexed: 01/27/2023]
Abstract
Transplant referral and evaluation are critical steps to waitlisting yet remain an elusive part of the transplant process. Despite calls for more data collection on pre-waitlisting steps, there are currently no national surveillance data to aid in understanding the causes and potential solutions for the extreme variation in access to transplantation. As population health scientists, epidemiologists, clinicians, and ethicists we submit that the transplant community has an obligation to better understand disparities in transplant access as a first necessary step to effectively mitigating these inequities. Our position is grounded in a population health approach, consistent with several new overarching national policy and quality initiatives. The purpose of this Perspective is to (1) provide an overview of how a population health approach should inform current multisystem policies impacting kidney transplantation and demonstrate how these efforts could be enhanced with national data collection on pre-waitlisting steps; (2) demonstrate the feasibility and concrete next steps for pre-waitlisting data collection; and (3) identify potential opportunities to use these data to implement effective population-level interventions, policies, and quality measures to improve equity in access to kidney transplantation.
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Affiliation(s)
- Rachel E Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
| | - Joel T Adler
- Department of Surgery, Division of Organ Transplantation, University of Massachusetts, Worcester, Massachusetts; Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jessica L Harding
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Anne Huml
- Case Center for Reducing Health Disparities, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Irene Kim
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Keren Ladin
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts; Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, Massachusetts
| | - Paulo N Martins
- Department of Surgery, Division of Organ Transplantation, University of Massachusetts, Worcester, Massachusetts
| | - Sumit Mohan
- Departments of Medicine and Epidemiology, Columbia University, New York, New York
| | - Katie Ross-Driscoll
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Stephen O Pastan
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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12
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McGill RL, Saunders MR, Hayward AL, Chapman AB. Health Disparities in Autosomal Dominant Polycystic Kidney Disease (ADPKD) in the United States. Clin J Am Soc Nephrol 2022; 17:976-985. [PMID: 35725555 PMCID: PMC9269641 DOI: 10.2215/cjn.00840122] [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: 01/19/2022] [Accepted: 04/14/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Autosomal dominant polycystic kidney disease (ADPKD) occurs at conception and is often diagnosed decades prior to kidney failure. Nephrology care and transplantation access should be independent of race and ethnicity. However, institutional racism and barriers to health care may affect patient outcomes in ADPKD. We sought to ascertain the effect of health disparities on outcomes in ADPKD by examining age at onset of kidney failure and access to preemptive transplantation and transplantation after dialysis initiation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Retrospective cohort analyses of adults with ADPKD in the United States Renal Data System from January 2000 to June 2018 were merged to US Census income data and evaluated by self-reported race and ethnicity. Age at kidney failure was analyzed in a linear model, and transplant rates before and after dialysis initiation were analyzed in logistic and proportional hazards models in Black and Hispanic patients with ADPKD compared with White patients with ADPKD. RESULTS A total of 41,485 patients with ADPKD were followed for a median of 25 (interquartile range, 5-54) months. Mean age was 56±12 years; 46% were women, 13% were Black, and 10% were Hispanic. Mean ages at kidney failure were 55±13, 53±12, and 57±12 years for Black patients, Hispanic patients, and White patients, respectively. Odds ratios for preemptive transplant were 0.33 (95% confidence interval, 0.29 to 0.38) for Black patients and 0.50 (95% confidence interval, 0.44 to 0.56) for Hispanic patients compared with White patients. Transplant after dialysis initiation was 0.61 (95% confidence interval, 0.58 to 0.64) for Black patients and 0.78 (95% confidence interval, 0.74 to 0.83) for Hispanic patients. CONCLUSIONS Black and Hispanic patients with ADPKD reach kidney failure earlier and are less likely to receive a kidney transplant preemptively and after initiating dialysis compared with White patients with ADPKD.
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Affiliation(s)
- Rita L McGill
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Milda R Saunders
- Section of General Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | | | - Arlene B Chapman
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois
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13
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The Kidney Transplant Equity Index: Improving Racial and Ethnic Minority Access to Transplantation. Ann Surg 2022; 276:420-429. [PMID: 35762615 DOI: 10.1097/sla.0000000000005549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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14
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Whelan AM, Johansen KL, Copeland T, McCulloch CE, Nallapothula D, Lee BK, Roll GR, Weir MR, Adey DB, Ku E. Kidney transplant candidacy evaluation and waitlisting practices in the United States and their association with access to transplantation. Am J Transplant 2022; 22:1624-1636. [PMID: 35289082 PMCID: PMC9177783 DOI: 10.1111/ajt.17031] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 02/20/2022] [Accepted: 03/09/2022] [Indexed: 01/25/2023]
Abstract
There are limited data on the degree of variability in practices surrounding prioritization of referrals for transplant evaluation and criteria for transplant candidacy and their association with transplantation rates. We surveyed transplant programs across the United States between January 2020 and May 2020 to determine current pre-transplantation practices. We examined the relation between these reported practices and the outcomes of waitlisted patients at responding programs between January 2015 and March 2021 using Scientific Registry of Transplant Recipients data. We used adjusted Cox models with random effects to accommodate clustering by program. Primary outcomes included living or deceased donor transplantation. Of 172 surveyed programs, 90 participated. Substantial variations were noted in when the candidacy evaluation began (13% reported when eGFR was <30 mL/min/1.73 m2 and 17% reported no set policy) and the approach to pre-transplantation cardiac workup (multi-modality [58%], stress echocardiogram [20%]). Using adjusted models, a program policy of using other measures of body habitus to determine transplant candidacy rather than requiring patients to meet a body mass index (BMI) threshold of ≤35 kg/m2 (reference group) for candidacy was associated with a higher hazard of living donor transplantation (HR 1.83 [95% CI 1.10-3.03]). Pre-transplant practices vary substantially across the United States, and select practices were associated with transplantation rates.
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Affiliation(s)
- Adrian M. Whelan
- University of California, San Francisco, Division of Nephrology, Department of Medicine
| | - Kirsten L. Johansen
- Hennepin County Medical Center and University of Minnesota, Division of Nephrology, Department of Medicine
| | - Timothy Copeland
- University of California, San Francisco, Division of Nephrology, Department of Medicine
| | - Charles E. McCulloch
- University of California, San Francisco, Department of Epidemiology and Biostatistics
| | | | - Brian K. Lee
- University of California, San Francisco, Division of Nephrology, Department of Medicine,University of Texas at Austin, Department of Internal Medicine
| | - Garrett R. Roll
- University of California, San Francisco, Division of Transplant Surgery, Department of Surgery
| | - Matthew R. Weir
- University of Maryland, Division of Nephrology, Department of Medicine
| | - Deborah B. Adey
- University of California, San Francisco, Division of Nephrology, Department of Medicine
| | - Elaine Ku
- University of California, San Francisco, Division of Nephrology, Department of Medicine,University of California, San Francisco, Department of Epidemiology and Biostatistics,University of California, San Francisco, Division of Pediatric Nephrology, Department of Pediatrics
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15
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Golenia A, Malyszko JS, Malyszko J. Cognitive impairment and kidney transplantation- underestimated, underrecognized but clinically relevant problem. Kidney Blood Press Res 2022; 47:459-466. [PMID: 35447625 DOI: 10.1159/000521907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 01/10/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) affects the crosstalk between organs in the body and vast majority of studies were devoted to the interactions between the kidneys and the cardiovascular system. As of today, there is more evidence of the kidney and the central nervous system connections. SUMMARY Indeed, CKD and in particular dialysis therapy is linked to the increased prevalence of neurological complications, such as cerebrovascular disorders, movement disorders, cognitive impairment, and depression. Both traditional cardiovascular risk factors (such as diabetes, hypertension, and lipid disorders), non-traditional risk factors (such as uremic toxins, anemia, secondary hyperparathyroidism) may predispose CKD patients to neurological disorders. Likewise, cognitive problems occur more commonly in kidney transplant recipients, regardless of age, than in the general population, but the prevalence is still understudied. Cognitive impairment is associated with a higher risk of hospitalization, mortality, decreased quality of life or health care costs in kidney transplant recipients. Here, we review (i) the potential clinical impact of kidney transplantation on cerebrovascular and neurological complications, (ii) evaluation of patients with cognitive impairment for kidney transplantation (iii) the potential impact cognitive impairment on waitlisted and transplanted patients on patient care, and (iv) unmet medical needs. KEY MESSAGES • Cognitive impairment in kidney transplant recipients is underestimated, underrecognized but clinically relevant problem. • The screening for cognitive declines after kidney transplantation is not yet a routine practice. • Several prospective and cross-sectional studies reported improvement across some of the assessed cognitive domains after transplantation.
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Affiliation(s)
| | - Jacek S Malyszko
- 1st Department of Nephrology and Transplantology, Medical University of Bialystok, Białystok, Poland
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
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16
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Hamid M, Rogers E, Chawla G, Gill J, Macanovic S, Mucsi I. Pretransplant Patient Education in Solid-organ Transplant: A Narrative Review. Transplantation 2022; 106:722-733. [PMID: 34260472 DOI: 10.1097/tp.0000000000003893] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Education for pretransplant, solid-organ recipient candidates aims to improve knowledge and understanding about the transplant process, outcomes, and potential complications to support informed, shared decision-making to reduce fears and anxieties about transplant, inform expectations, and facilitate adjustment to posttransplant life. In this review, we summarize novel pretransplant initiatives and approaches to educate solid-organ transplant recipient candidates. First, we review approaches that may be common to all solid-organ transplants, then we summarize interventions specific to kidney, liver, lung, and heart transplant. We describe evidence that emphasizes the need for multidisciplinary approaches to transplant education. We also summarize initiatives that consider online (eHealth) and mobile (mHealth) solutions. Finally, we highlight education initiatives that support racialized or otherwise marginalized communities to improve equitable access to solid-organ transplant. A considerable amount of work has been done in solid-organ transplant since the early 2000s with promising results. However, many studies on education for pretransplant recipient candidates involve relatively small samples and nonrandomized designs and focus on short-term surrogate outcomes. Overall, many of these studies have a high risk of bias. Frequently, interventions assessed are not well characterized or they are combined with administrative and data-driven initiatives into multifaceted interventions, which makes it difficult to assess the impact of the education component on outcomes. In the future, well-designed studies rigorously assessing well-defined surrogate and clinical outcomes will be needed to evaluate the impact of many promising initiatives.
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Affiliation(s)
- Marzan Hamid
- Multi-Organ Transplant Program and Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
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17
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A scoping review of inequities in access to organ transplant in the United States. Int J Equity Health 2022; 21:22. [PMID: 35151327 PMCID: PMC8841123 DOI: 10.1186/s12939-021-01616-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 12/24/2021] [Indexed: 02/06/2023] Open
Abstract
Background Organ transplant is the preferred treatment for end-stage organ disease, yet the majority of patients with end-stage organ disease are never placed on the transplant waiting list. Limited access to the transplant waiting list combined with the scarcity of the organ pool result in over 100,000 deaths annually in the United States. Patients face unique barriers to referral and acceptance for organ transplant based on social determinants of health, and patients from disenfranchised groups suffer from disproportionately lower rates of transplantation. Our objective was to review the literature describing disparities in access to organ transplantation based on social determinants of health to integrate the existing knowledge and guide future research. Methods We conducted a scoping review of the literature reporting disparities in access to heart, lung, liver, pancreas and kidney transplantation based on social determinants of health (race, income, education, geography, insurance status, health literacy and engagement). Included studies were categorized based on steps along the transplant care continuum: referral for transplant, transplant evaluation and selection, living donor identification/evaluation, and waitlist outcomes. Results Our search generated 16,643 studies, of which 227 were included in our final review. Of these, 34 focused on disparities in referral for transplantation among patients with chronic organ disease, 82 on transplant selection processes, 50 on living donors, and 61 on waitlist management. In total, 15 studies involved the thoracic organs (heart, lung), 209 involved the abdominal organs (kidney, liver, pancreas), and three involved multiple organs. Racial and ethnic minorities, women, and patients in lower socioeconomic status groups were less likely to be referred, evaluated, and added to the waiting list for organ transplant. The quality of the data describing these disparities across the transplant literature was variable and overwhelmingly focused on kidney transplant. Conclusions This review contextualizes the quality of the data, identifies seminal work by organ, and reports gaps in the literature where future research on disparities in organ transplantation should focus. Future work should investigate the association of social determinants of health with access to the organ transplant waiting list, with a focus on prospective analyses that assess interventions to improve health equity. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-021-01616-x.
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18
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Adekunle RO, Zhang R, Wang Z, Patzer RE, Mehta AK. Early steps to kidney transplantation among persons with HIV and end-stage renal disease in ESRD network 6. Transpl Infect Dis 2022; 24:e13767. [PMID: 34813136 PMCID: PMC8825692 DOI: 10.1111/tid.13767] [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: 04/08/2021] [Revised: 10/18/2021] [Accepted: 11/10/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION End-stage renal disease is a significant cause of morbidity and mortality in persons with HIV (PWH). Limited data exist on access to kidney transplantation for this population. METHODS A dataset inclusive of incident dialysis patients between 2012 and 2016 with follow-up through December 2017 that identifies PWH and the general dialysis population of Network 6 (Georgia, North Carolina, South Carolina) was created through merging the United States Renal Data System with the southeastern early transplant access registry. Early steps to kidney transplantation and patient and dialysis facility-level characteristics that serve as barriers to transplantation were described. RESULTS Twenty-three thousand four hundred fourteen patients were identified; 469 were PWH. Compared to non-HIV individuals, PWH were younger (49 vs. 58 years, p < 0.001), predominantly Black (87% vs. 56% p < 0.001) and male (72% vs. 56% p < 0.001). PWH were less likely to be referred to kidney transplant within 1 year of starting dialysis (36% vs. 41% p < 0.001) and waitlisted within 1 year of evaluation-start (14% vs. 30%, p = 0.05). PWH (vs. non-PWH) waited longer for referral, evaluation-start, and waitlisting and in multivariable analysis; HIV positivity was associated with a lower probability of referral (hazard ratios [HR]: 0.70; 95% confidence intervals [CIs]: 0.62-0.80), evaluation (HR 0.66; 95% CI: 0.55-0.80), and waitlisting (HR 0.29; 95% CI: 0.20-0.41). CONCLUSIONS Targeted interventions are needed to improve access to kidney transplants, particularly in waitlisting, for PWH.
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Affiliation(s)
- Ruth O Adekunle
- Division of Infectious Diseases, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Rebecca Zhang
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Zhengsheng Wang
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E Patzer
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Aneesh K Mehta
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia Emory Transplant Center, Atlanta, Georgia,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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19
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Morinelli TA, Taber DJ, Su Z, Rodrigue JR, Sutton Z, Chastain M, Tindal TT, Weeda E, Mauldin PD, Casey M, Bian J, Baliga P, DuBay DA. A Dialysis Center Educational Video Intervention Increases Patient Self-Efficacy and Kidney Transplant Evaluations. Prog Transplant 2021; 32:27-34. [PMID: 34874194 DOI: 10.1177/15269248211064882] [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: 11/15/2022]
Abstract
Introduction: The optimal treatment for end-stage kidney disease is renal transplant. However, only 1 in 5 (21.5%) patients nationwide receiving dialysis are on a transplant waitlist. Factors associated with patients not initiating a transplant evaluation are complex and include patient specific factors such as transplant knowledge and self-efficacy. Research Question: Can a dialysis center-based educational video intervention increase dialysis patients' transplant knowledge, self-efficacy, and transplant evaluations initiated? Design: Dialysis patients who had not yet completed a transplant evaluation were provided a transplant educational video while receiving hemodialysis. Patients' transplant knowledge, self-efficacy to initiate an evaluation, and dialysis center rates of transplant referral and evaluation were assessed before and after this intervention. Results: Of 340 patients approached at 14 centers, 252 (74%) completed the intervention. The intervention increased transplant knowledge (Likert scale 1 to 5: 2.53 [0.10] vs 4.62 [0.05], P < .001) and transplant self-efficacy (2.55 [0.10] to 4.33 [0.07], P < .001. The incidence rate per 100 patient years of transplant evaluations increased 85% (IRR 1.85 [95% CI: 1.02, 3.35], P = .0422) following the intervention. The incidence rates of referrals also increased 56% (IRR 1.56 [95% CI: 1.03, 2.37], P = .0352), while there was a nonsignificant 47% increase in incidence rates of waitlist entries (IRR 1.47 [95% CI: 0.45, 4.74], P = .5210). Conclusion: This dialysis center-based video intervention provides promising preliminary evidence to conduct a large-scale randomized controlled trial to test its effectiveness in increasing self-efficacy of dialysis patients to initiate a transplant evaluation.
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Affiliation(s)
| | - David J Taber
- Medical University of South Carolina, Charleston, SC, USA.,Ralph H. Johnson Veterans' Hospital, Charleston, SC, USA
| | - Zemin Su
- Medical University of South Carolina, Charleston, SC, USA
| | - James R Rodrigue
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Zachary Sutton
- Medical University of South Carolina, Charleston, SC, USA
| | - Misty Chastain
- Medical University of South Carolina, Charleston, SC, USA
| | | | - Erin Weeda
- Medical University of South Carolina, Charleston, SC, USA
| | | | - Michael Casey
- Medical University of South Carolina, Charleston, SC, USA
| | - John Bian
- Medical University of South Carolina, Charleston, SC, USA
| | | | - Derek A DuBay
- Medical University of South Carolina, Charleston, SC, USA
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20
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Kayler LK, Dolph B, Ranahan M, Keller M, Cadzow R, Feeley TH. Kidney Transplant Evaluation and Listing: Development and Preliminary Evaluation of Multimedia Education for Patients. Ann Transplant 2021; 26:e929839. [PMID: 33649286 PMCID: PMC7936469 DOI: 10.12659/aot.929839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Patient knowledge gaps about the evaluation and waitlisting process for kidney transplantation lead to delayed and incomplete testing, which compromise transplant access. We aimed to develop and evaluate a novel video education approach to empower patients to proceed with the transplant evaluation and listing process and to increase their knowledge and motivation. Material/Methods We developed 2 theory-informed educational animations about the kidney transplantation evaluation and listing process with input from experts in transplantation and communication, 20 candidates/recipients, 5 caregivers, 1 anthropologist, 3 community advocates, and 36 dialysis or transplant providers. We then conducted an online pre-post study with 28 kidney transplantation candidates to measure the acceptability and feasibility of the 2 videos to improve patients’ evaluation and listing knowledge, understanding, and concerns. Results Compared with before intervention, the mean knowledge score increased after intervention by 38% (5.7 to 7.9; P<0.001). Increases in knowledge effect size were large across age group, health literacy, education, technology access, and duration of pretransplant dialysis. The proportion of positive responses increased from before to after animation viewing for understanding the evaluation process (25% to 61%; P=0.002) and waitlist placement (32% to 86%; P<0.001). Concerns about list placement decreased (32% to 7%; P=0.039). After viewing the animations, >90% of responses indicated positive ratings on trusting the information, comfort level with learning, and engagement. Conclusions In partnership with stakeholders, we developed 2 educational animations about kidney transplant evaluation and listing that were positively received by patients and have the potential to improve patient knowledge and understanding and reduce patient concerns.
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Affiliation(s)
- Liise K Kayler
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA.,Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, Buffalo, NY, USA
| | - Beth Dolph
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Molly Ranahan
- Transplant and Kidney Care Regional Center of Excellence, Erie County Medical Center, Buffalo, NY, USA
| | - Maria Keller
- Department of Community Health and Health Behavior, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Renee Cadzow
- Department of Health Administration and Public Health, D'Youville College, Buffalo, NY, USA
| | - Thomas H Feeley
- Department of Communication, University at Buffalo, State University of New York, Buffalo, NY, USA
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21
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Waterman AD, Peipert JD, Cui Y, Beaumont JL, Paiva A, Lipsey AF, Anderson CS, Robbins ML. Your Path to Transplant: A randomized controlled trial of a tailored expert system intervention to increase knowledge, attitudes, and pursuit of kidney transplant. Am J Transplant 2021; 21:1186-1196. [PMID: 33245618 PMCID: PMC7882639 DOI: 10.1111/ajt.16262] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 01/25/2023]
Abstract
Individually tailoring education over time may help more patients, especially racial/ethnic minorities, get waitlisted and pursue deceased and living donor kidney transplant (DDKT and LDKT, respectively). We enrolled 802 patients pursuing transplant evaluation at the University of California, Los Angeles Transplant Program into a randomized education trial. We compared the effectiveness of Your Path to Transplant (YPT), an individually tailored coaching and education program delivered at 4 time points, with standard of care (SOC) education on improving readiness to pursue DDKT and LDKT, transplant knowledge, taking 15 small transplant-related actions, and pursuing transplant (waitlisting or LDKT rates) over 8 months. Survey outcomes were collected prior to evaluation and at 4 and 8 months. Time to waitlisting or LDKT was assessed with at least 18 months of follow-up. At 8 months, compared to SOC, the YPT group demonstrated increased LDKT readiness (47% vs 33%, P = .003) and transplant knowledge (effect size [ES] = 0.41, P < .001). Transplant pursuit was higher in the YPT group (hazard ratio: 1.44, 95% confidence interval: 1.15-1.79, P = .002). A focused, coordinated education effort can improve transplant-seeking behaviors and waitlisting rates. ClinicalTrials.gov registration: NCT02181114.
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Affiliation(s)
- Amy D. Waterman
- Division of Nephrology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California,Terasaki Institute of Biomedical Innovation, Los Angeles, California
| | - John D. Peipert
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University,Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Chicago, IL
| | - Yujie Cui
- Terasaki Institute of Biomedical Innovation, Los Angeles, California
| | | | - Andrea Paiva
- Department of Psychology, The University of Rhode Island, Kingston, RI
| | - Amanda F. Lipsey
- Division of Nephrology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California,Terasaki Institute of Biomedical Innovation, Los Angeles, California
| | - Crystal S. Anderson
- Division of Nephrology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Mark L. Robbins
- Department of Psychology, The University of Rhode Island, Kingston, RI
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22
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Ku E, McCulloch CE, Adey DB, Li L, Johansen KL. Racial Disparities in Eligibility for Preemptive Waitlisting for Kidney Transplantation and Modification of eGFR Thresholds to Equalize Waitlist Time. J Am Soc Nephrol 2021; 32:677-685. [PMID: 33622978 PMCID: PMC7920175 DOI: 10.1681/asn.2020081144] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/07/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Patients may accrue wait time for kidney transplantation when their eGFR is ≤20 ml/min. However, Black patients have faster progression of their kidney disease compared with White patients, which may lead to disparities in accruable time on the kidney transplant waitlist before dialysis initiation. METHODS We compared differences in accruable wait time and transplant preparation by CKD-EPI estimating equations in Chronic Renal Insufficiency Cohort participants, on the basis of estimates of kidney function by creatinine (eGFRcr), cystatin C (eGFRcys), or both (eGFRcr-cys). We used Weibull accelerated failure time models to determine the association between race (non-Hispanic Black or non-Hispanic White) and time to ESKD from an eGFR of ≤20 ml/min per 1.73 m2. We then estimated how much higher the eGFR threshold for waitlisting would be required to achieve equity in accruable preemptive wait time for the two groups. RESULTS By eGFRcr, 444 CRIC participants were eligible for waitlist registration, but the potential time between eGFR ≤20 ml/min per 1.73 m2 and ESKD was 32% shorter for Blacks versus Whites. By eGFRcys, 435 participants were eligible, and Blacks had 35% shorter potential wait time compared with Whites. By the eGFRcr-cys equation, 461 participants were eligible, and Blacks had a 31% shorter potential wait time than Whites. We estimated that registering Blacks on the waitlist as early as an eGFR of 24-25 ml/min per 1.73 m2 might improve racial equity in accruable wait time before ESKD onset. CONCLUSIONS Policies allowing for waitlist registration at higher GFR levels for Black patients compared with White patients could theoretically attenuate disparities in accruable wait time and improve racial equity in transplant access.
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Affiliation(s)
- Elaine Ku
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Deborah B. Adey
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Libo Li
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Kirsten L. Johansen
- Division of Nephrology, Department of Medicine and University of Minnesota, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
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23
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Wesselman H, Ford CG, Leyva Y, Li X, Chang CCH, Dew MA, Kendall K, Croswell E, Pleis JR, Ng YH, Unruh ML, Shapiro R, Myaskovsky L. Social Determinants of Health and Race Disparities in Kidney Transplant. Clin J Am Soc Nephrol 2021; 16:262-274. [PMID: 33509963 PMCID: PMC7863655 DOI: 10.2215/cjn.04860420] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 11/16/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Black patients have a higher incidence of kidney failure but lower rate of deceased- and living-donor kidney transplantation compared with White patients, even after taking differences in comorbidities into account. We assessed whether social determinants of health (e.g., demographics, cultural, psychosocial, knowledge factors) could account for race differences in receiving deceased- and living-donor kidney transplantation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Via medical record review, we prospectively followed 1056 patients referred for kidney transplant (2010-2012), who completed an interview soon after kidney transplant evaluation, until their kidney transplant. We used multivariable competing risk models to estimate the cumulative incidence of receipt of any kidney transplant, deceased-donor transplant, or living-donor transplant, and the factors associated with each outcome. RESULTS Even after accounting for social determinants of health, Black patients had a lower likelihood of kidney transplant (subdistribution hazard ratio, 0.74; 95% confidence interval, 0.55 to 0.99) and living-donor transplant (subdistribution hazard ratio, 0.49; 95% confidence interval, 0.26 to 0.95), but not deceased-donor transplant (subdistribution hazard ratio, 0.92; 95% confidence interval, 0.67 to 1.26). Black race, older age, lower income, public insurance, more comorbidities, being transplanted before changes to the Kidney Allocation System, greater religiosity, less social support, less transplant knowledge, and fewer learning activities were each associated with a lower probability of any kidney transplant. Older age, more comorbidities, being transplanted before changes to the Kidney Allocation System, greater religiosity, less social support, and fewer learning activities were each associated with a lower probability of deceased-donor transplant. Black race, older age, lower income, public insurance, higher body mass index, dialysis before kidney transplant, not presenting with a potential living donor, religious objection to living-donor transplant, and less transplant knowledge were each associated with a lower probability of living-donor transplant. CONCLUSIONS Race and social determinants of health are associated with the likelihood of undergoing kidney transplant.
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Affiliation(s)
- Hannah Wesselman
- Department of Biological Sciences, University of Notre Dame, Notre Dame, Indiana
| | - Christopher Graham Ford
- Center for Healthcare Equity in Kidney Disease, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Yuridia Leyva
- Center for Healthcare Equity in Kidney Disease, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Xingyuan Li
- Eli Lilly and Company, Indianapolis, Indiana
| | - Chung-Chou H. Chang
- Department of Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania,Department of Biostatistics, University of Pittsburgh, Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Mary Amanda Dew
- Department of Psychiatry, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
| | - Kellee Kendall
- Department of Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
| | - Emilee Croswell
- Department of Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
| | - John R. Pleis
- Division of Research and Methodology, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
| | - Yue Harn Ng
- Department of Internal Medicine, University of New Mexico, School of Medicine, Albuquerque, New Mexico
| | - Mark L. Unruh
- Department of Internal Medicine, University of New Mexico, School of Medicine, Albuquerque, New Mexico
| | - Ron Shapiro
- Mount Sinai Recanati/Miller Transplantation Institute, Icahn School of Medicine, New York, New York
| | - Larissa Myaskovsky
- Center for Healthcare Equity in Kidney Disease, University of New Mexico Health Sciences Center, Albuquerque, New Mexico,Department of Internal Medicine, University of New Mexico, School of Medicine, Albuquerque, New Mexico
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24
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Rohan VS, Pilch N, Cassidy D, McGillicuddy J, White J, Lin A, Nadig SN, Taber DJ, Dubay D, Baliga PK. Maintaining Equity and Access: Successful Implementation of a Virtual Kidney Transplantation Evaluation. J Am Coll Surg 2020; 232:444-449. [PMID: 33359232 DOI: 10.1016/j.jamcollsurg.2020.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Maintaining access to kidney transplantation during a pandemic is a challenge, particularly for centers that serve a large rural and minority patient population with an additional burden of travel. The aim of this article was to describe our experience with the rollout and use of a virtual pretransplantation evaluation platform to facilitate ongoing transplant waitlisting during the early peak of the COVID-19 pandemic. STUDY DESIGN This is a retrospective analysis of the process improvement project implemented to continue the evaluation of potential kidney transplantation candidates and ensure waitlist placement during the COVID-19 pandemic. Operational metrics include transplantation volume per month, referral volume per month, pretransplantation patients halted before completing an evaluation per month, evaluations completed per month, and patients waitlisted per month. RESULTS Between April and September 2020, a total of 1,258 patients completed an evaluation. Two hundred and forty-seven patients were halted during this time period before completing a full evaluation. One hundred and fifty-two patients were presented at selection and 113 were placed on the waitlist. In addition, the number of patients in the active referral phase was able to be reduced by 46%. More evaluations were completed within the virtual platform (n = 930 vs n = 880), yielding similar additions to the waitlist in 2020 (n = 282) vs 2019 (n = 308) despite the COVID-19 pandemic. CONCLUSIONS The virtual platform allowed continued maintenance of a large kidney transplantation program despite the inability to have in-person visits. The value of this platform will likely transform our approach to the pretransplantation process and provides an additional valuable method to improve patient equity and access to transplantation.
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Affiliation(s)
- Vinayak S Rohan
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina.
| | - Nicole Pilch
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - Deborah Cassidy
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - John McGillicuddy
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - Jared White
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - Angello Lin
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - Satish N Nadig
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - David J Taber
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - Derek Dubay
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
| | - Prabhakar K Baliga
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, College of Medicine, Charleston, South Carolina
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25
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Tiong MK, Thomas S, Fernandes DK, Cherian S. Examining barriers to timely waitlisting for kidney transplantation for Indigenous Australians in Central Australia. Intern Med J 2020; 52:288-294. [PMID: 33251718 DOI: 10.1111/imj.14960] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 06/14/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Indigenous Australians are disproportionately affected by end stage kidney disease. Despite this, they face significant delays being assessed and waitlisted for kidney transplant. AIMS To examine the kidney transplant waitlisting process in our region, to compare the workup process between Indigenous Australians and non-Indigenous patients, and identify major sources of delay. METHODS We analysed the records of all patients being treated by our service who were on the kidney transplant waitlist between January 2017 and June 2018. Between-group differences were used to compare the time between commencement of dialysis and completion of each component of assessment. Patients who had more than 1 year between commencement of dialysis and waitlisting were further analysed for major sources of delay. RESULTS Twenty-five patients were included (20 Indigenous Australians and 5 non-Indigenous). The median time to waitlisting for transplant after commencing dialysis was significantly longer in the Indigenous group (1215 vs 264 days, P = 0.032). Indigenous Australian patients waited longer before commencing the transplant assessment process and before completing dental assessment, tissue typing and review by the transplant nephrologist and surgeon. Five patients (two Indigenous Australians, three non-Indigenous) were waitlisted within 1 year of commencing dialysis. Among the remaining 20 patients, cardiac and systems issues were the two most common major sources of delay. CONCLUSION Indigenous Australian patients face significant delays accessing the kidney transplant waitlist. Cardiac assessment and systems issues are prominent sources of delay and efforts to address these areas may help to improve equity of access to kidney transplantation.
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Affiliation(s)
- Mark K Tiong
- Central Australian Renal Service, Alice Springs Hospital, Alice Springs, Northern Territory, Australia.,Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) Aboriginal and Torres Strait Islander Working Group, Adelaide, South Australia, Australia
| | - Sajan Thomas
- Central Australian Renal Service, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - David K Fernandes
- Central Australian Renal Service, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Sajiv Cherian
- Central Australian Renal Service, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
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26
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Does Racial Disparity in Kidney Transplant Waitlisting Persist After Accounting for Social Determinants of Health? Transplantation 2020; 104:1445-1455. [PMID: 31651719 DOI: 10.1097/tp.0000000000003002] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND African Americans (AA) have lower rates of kidney transplantation (KT) compared with Whites (WH), even after adjusting for demographic and medical factors. In this study, we examined whether the racial disparity in KT waitlisting persists after adjusting for social determinants of health (eg, cultural, psychosocial, and knowledge). METHODS We prospectively followed a cohort of 1055 patients who were evaluated for KT between 3 of 10 to 10 of 12 and followed through 8 of 18. Participants completed a semistructured telephone interview shortly after their first KT evaluation appointment. We used the Wilcoxon rank-sum and Pearson chi-square tests to examine race differences in the baseline characteristics. We then assessed racial differences in the probability of waitlisting while accounting for all predictors using cumulative incidence curves and Fine and Gray proportional subdistribution hazards models. RESULTS There were significant differences in the baseline characteristics between non-Hispanic AA and non-Hispanic WH. AA were 25% less likely (95% confidence interval, 0.60-0.96) to be waitlisted than WH even after adjusting for medical factors and social determinants of health. In addition, being older, having lower income, public insurance, more comorbidities, and being on dialysis decreased the probability of waitlisting while having more social support and transplant knowledge increased the probability of waitlisting. CONCLUSIONS Racial disparity in kidney transplant waitlisting persisted even after adjusting for medical factors and social determinants of health, suggesting the need to identify novel factors that impact racial disparity in transplant waitlisting. Developing interventions targeting cultural and psychosocial factors may enhance equity in access to transplantation.
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27
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Abstract
Kidney transplantation is the ideal treatment option for patients with end-stage kidney disease (ESKD). Since there is clear mortality benefit to receiving a transplant regardless of comorbidities and age, the gold standard of care should focus on attaining kidney transplantation and minimizing, or better yet eliminating, time on dialysis. Unfortunately, only a small percentage of patients with ESKD receive a kidney transplant. Several barriers to kidney transplantation have been identified. Barriers can largely be grouped into three categories: patient-related, physician/provider-related, and system-related. Several barriers fall into multiple categories and play a role at various levels within the healthcare system. Acknowledging and understanding these barriers will allow transplant centers and dialysis facilities to make the necessary interventions to mitigate these disparities, optimize the transplant evaluation process, and improve patient outcomes. This review will discuss these barriers and potential interventions to increase access to kidney transplantation.
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28
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Huml AM, Sedor JR, Poggio E, Patzer RE, Schold JD. An opt-out model for kidney transplant referral: The time has come. Am J Transplant 2020; 21:32-36. [PMID: 32519382 PMCID: PMC7725926 DOI: 10.1111/ajt.16129] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 05/14/2020] [Accepted: 06/01/2020] [Indexed: 01/25/2023]
Abstract
Disparities that affect equity in access to kidney transplantation for patients with kidney failure have been well described. Many robust clinical trials have tested the effectiveness of interventions to reduce disparities and equilibrate access to kidney transplantation. Moreover, policy changes have been enacted to achieve the same aims. Despite these efforts, rates of kidney transplant waitlisting within the first year of end-stage kidney disease have remained unchanged over the past 2 decades, while incident rates of end-stage kidney disease have climbed. Because prior interventions have not durably increased transplant access, disruptive change is clearly needed. The Advancing American Kidney Health Executive Order sets bold goals to transform kidney care for patients and caregivers. In this spirit, we discuss an Opt-Out for Transplant Referral Model as a compelling solution to improve equity in access to kidney transplantation.
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Affiliation(s)
- Anne M. Huml
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic
| | - John R. Sedor
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic
| | - Emilio Poggio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic
| | - Rachel E. Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine,Department of Epidemiology, Emory University Rollins School of Public Health
| | - Jesse D Schold
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic,Department of Quantitative Health Sciences, Cleveland Clinic
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29
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Murphy KA, Jackson JW, Purnell TS, Shaffer AA, Haugen CE, Chu NM, Crews DC, Norman SP, Segev DL, McAdams-DeMarco MA. Association of Socioeconomic Status and Comorbidities with Racial Disparities during Kidney Transplant Evaluation. Clin J Am Soc Nephrol 2020; 15:843-851. [PMID: 32381582 PMCID: PMC7274281 DOI: 10.2215/cjn.12541019] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 03/16/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Black patients referred for kidney transplantation have surpassed many obstacles but likely face continued racial disparities before transplant. The mechanisms that underlie these disparities are unclear. We determined the contributions of socioeconomic status (SES) and comorbidities as mediators to disparities in listing and transplant. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We studied a cohort (n=1452 black; n=1561 white) of patients with kidney failure who were referred for and started the transplant process (2009-2018). We estimated the direct and indirect effects of SES (self-reported income, education, and employment) and medical comorbidities (self-reported and chart-abstracted) as mediators of racial disparities in listing using Cox proportional hazards analysis with inverse odds ratio weighting. Among the 983 black and 1085 white candidates actively listed, we estimated the direct and indirect effects of SES and comorbidities as mediators of racial disparities on receipt of transplant using Poisson regression with inverse odds ratio weighting. RESULTS Within the first year, 876 (60%) black and 1028 (66%) white patients were waitlisted. The relative risk of listing for black compared with white patients was 0.76 (95% confidence interval [95% CI], 0.69 to 0.83); after adjustment for SES and comorbidity, the relative risk was 0.90 (95% CI, 0.83 to 0.97). The proportion of the racial disparity in listing was explained by SES by 36% (95% CI, 26% to 57%), comorbidity by 44% (95% CI, 35% to 61%), and SES with comorbidity by 58% (95% CI, 44% to 85%). There were 409 (42%) black and 496 (45%) white listed candidates transplanted, with a median duration of follow-up of 3.9 (interquartile range, 1.2-7.1) and 2.8 (interquartile range, 0.8-6.3) years, respectively. The incidence rate ratio for black versus white candidates was 0.87 (95% CI, 0.79 to 0.96); SES and comorbidity did not explain the racial disparity. CONCLUSIONS SES and comorbidity partially mediated racial disparities in listing but not for transplant.
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Affiliation(s)
- Karly A Murphy
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - John W Jackson
- Johns Hopkins Center for Health Equity, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Tanjala S Purnell
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Johns Hopkins Center for Health Equity, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ashton A Shaffer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Christine E Haugen
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nadia M Chu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Deidra C Crews
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Johns Hopkins Center for Health Equity, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Silas P Norman
- Division of Nephrology, Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Dorry L Segev
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Mara A McAdams-DeMarco
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland .,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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30
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Use of Patient Navigators to Reduce Barriers in Living Donation and Living Donor Transplantation. CURRENT TRANSPLANTATION REPORTS 2020. [DOI: 10.1007/s40472-020-00280-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Patzer RE, Pastan SO. Policies to promote timely referral for kidney transplantation. Semin Dial 2020; 33:58-67. [PMID: 31957930 DOI: 10.1111/sdi.12860] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/14/2019] [Indexed: 02/06/2023]
Abstract
There are numerous patient, provider, and health system barriers to accessing kidney transplantation. Patient barriers such as sociocultural and clinical characteristics and provider factors such as provider knowledge and awareness of transplantation play important roles in facilitating transplant. Health system factors like misaligned incentives and quality metrics for dialysis facilities and transplant centers also influence transplant access. While numerous studies have documented the impact of these barriers on wait-listing and transplant, few studies have examined referral from a dialysis facility to a transplant center and start of the transplant evaluation process. While the Centers for Medicare and Medicaid Services (CMS) require that dialysis facilities educate patients about transplant, there are no guidelines for the content and objectives for this education. In addition, policies to require timely referral for transplantation have been considered by CMS but are difficult to implement without national data on referral. Federal policies should be amended to mandate transplant center submission of referral data-while decreasing the unfunded mandate to collect other unusable data currently collected as part of regulatory monitoring of transplant centers-to promote timely access to transplant, increased transplant rates, and to better understand the multilevel barriers and facilitators to transplant referral.
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Affiliation(s)
- Rachel E Patzer
- Department of Medicine, Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA.,Department of Surgery, Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA.,Emory Transplant Center, Atlanta, GA, USA.,Department of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
| | - Stephen O Pastan
- Department of Medicine, Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA.,Department of Surgery, Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA.,Emory Transplant Center, Atlanta, GA, USA.,Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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32
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Hamoda RE, McPherson LJ, Lipford K, Jacob Arriola K, Plantinga L, Gander JC, Hartmann E, Mulloy L, Zayas CF, Lee KN, Pastan SO, Patzer RE. Association of sociocultural factors with initiation of the kidney transplant evaluation process. Am J Transplant 2020; 20:190-203. [PMID: 31278832 DOI: 10.1111/ajt.15526] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 06/21/2019] [Accepted: 06/25/2019] [Indexed: 01/25/2023]
Abstract
Although research shows that minorities exhibit higher levels of medical mistrust, perceived racism, and discrimination in healthcare settings, the degree to which these underlying sociocultural factors preclude end-stage renal disease (ESRD) patients from initiating kidney transplant evaluation is unknown. We telephone surveyed 528 adult ESRD patients of black or white race referred for evaluation to a Georgia transplant center (N = 3) in 2014-2016. We used multivariable logistic regression to examine associations between sociocultural factors and evaluation initiation, adjusting for demographic, clinical, and socioeconomic characteristics. Despite blacks (n = 407) reporting higher levels of medical mistrust (40.0% vs 26.4%, P < .01), perceived racism (55.5% vs 18.2%, P < .01), and experienced discrimination (29.0% vs 15.7%, P < .01) than whites (n = 121), blacks were only slightly less likely than whites to initiate evaluation (49.6% vs 57.9%, P = .11). However, after adjustment, medical mistrust (odds ratio [OR]: 0.59; 95% confidence interval [CI]: 0.39, 0.91), experienced discrimination (OR: 0.62, 95% CI: 0.41, 0.95), and perceived racism (OR: 0.61; 95% CI: 0.40, 0.92) were associated with lower evaluation initiation. Results suggest that sociocultural disparities exist in early kidney transplant access and occur despite the absence of a significant racial disparity in evaluation initiation. Interventions to reduce disparities in transplantation access should target underlying sociocultural factors, not just race.
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Affiliation(s)
- Reem E Hamoda
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Laura J McPherson
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Kristie Lipford
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Kimberly Jacob Arriola
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Laura Plantinga
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, USA
| | | | | | - Laura Mulloy
- Augusta University Kidney and Pancreas Transplant Program, Augusta University Medical Center, Augusta, Georgia
| | - Carlos F Zayas
- Augusta University Kidney and Pancreas Transplant Program, Augusta University Medical Center, Augusta, Georgia
| | - Kyung Na Lee
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Stephen O Pastan
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.,Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, USA
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33
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Cervantes L, Hasnain-Wynia R, Steiner JF, Chonchol M, Fischer S. Patient Navigation: Addressing Social Challenges in Dialysis Patients. Am J Kidney Dis 2019; 76:121-129. [PMID: 31515136 DOI: 10.1053/j.ajkd.2019.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 06/15/2019] [Indexed: 01/13/2023]
Abstract
Members of racial and ethnic minority groups make up nearly 50% of US patients with end-stage kidney disease and face a disproportionate burden of socioeconomic challenges (ie, low income, job insecurity, low educational attainment, housing instability, and communication challenges) compared with non-Hispanic whites. Patients with end-stage kidney disease who face social challenges often have poor patient-centered and clinical outcomes. These challenges may have a negative impact on quality-of-care performance measures for dialysis facilities caring for primarily minority and low-income patients. One path toward improving outcomes for this group is to develop culturally tailored interventions that provide individualized support, potentially improving patient-centered, clinical, and health system outcomes by addressing social challenges. One such approach is using community-based culturally and linguistically concordant patient navigators, who can serve as a bridge between the patient and the health care system. Evidence points to the effectiveness of patient navigators in the provision of cancer care and, to a lesser extent, caring for people with chronic kidney disease and those who have undergone kidney transplantation. However, little is known about the effectiveness of patient navigators in the care of patients with kidney failure receiving dialysis, who experience a number of remediable social challenges.
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Affiliation(s)
- Lilia Cervantes
- Division of Hospital Medicine, Denver Health, Denver, CO; Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Denver, CO; Office of Research, Denver Health, Denver, CO.
| | | | - John F Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO
| | - Michel Chonchol
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Denver, CO
| | - Stacy Fischer
- Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Denver, CO
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34
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Affiliation(s)
- Rachel E Patzer
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA
- Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Rollins School of Public Health, Atlanta, GA
| | - Christian P Larsen
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA
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Harhay MN, Reese PP. Frailty and Cognitive Deficits Limit Access to Kidney Transplantation: Unfair or Unavoidable? Clin J Am Soc Nephrol 2019; 14:493-495. [PMID: 30890579 PMCID: PMC6450350 DOI: 10.2215/cjn.02390219] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Meera N Harhay
- Division of Nephrology and Hypertension, Drexel University College of Medicine, Philadelphia, Pennsylvania.,Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania; and
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division and .,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
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Warsame F, Haugen CE, Ying H, Garonzik-Wang JM, Desai NM, Hall RK, Kambhampati R, Crews DC, Purnell TS, Segev DL, McAdams-DeMarco MA. Limited health literacy and adverse outcomes among kidney transplant candidates. Am J Transplant 2019; 19:457-465. [PMID: 29962069 PMCID: PMC6312744 DOI: 10.1111/ajt.14994] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/08/2018] [Accepted: 06/07/2018] [Indexed: 01/25/2023]
Abstract
More than one-third of US adults have limited health literacy, putting them at risk of adverse clinical outcomes. We evaluated the prevalence of limited health literacy among 1578 adult kidney transplant (KT) candidates (May 2014-November 2017) and examined its association with listing for transplant and waitlist mortality in this pilot study. Limited health literacy was assessed at KT evaluation by using a standard cutoff score ≤5 on the Brief Health Literacy Screen (score range 0-12, lower scores indicate worse health literacy). We used logistic regression and adjusted Cox proportional hazards models to identify risk factors for limited health literacy and to quantify its association with listing and waitlist mortality. We found that 8.9% of candidates had limited health literacy; risk factors included less than college education (adjusted odds ratio [aOR] = 2.87, 95% confidence interval [CI]:1.86-4.43), frailty (aOR = 1.85, 95% CI:1.22-2.80), comorbidity (Charlson comorbidity index [1-point increase] aOR = 1.12, 95% CI: 1.04-1.20), and cognitive impairment (aOR = 3.45, 95% CI: 2.20-5.41) after adjusting for age, sex, race, and income. Candidates with limited health literacy had a 30% (adjusted hazard ratio = 0.70, 95% CI: 0.54-0.91) decreased likelihood of listing and a 2.42-fold (95% CI: 1.16- to 5.05-fold) increased risk of waitlist mortality. Limited health literacy may be a salient mechanism in access to KT; programs to aid candidates with limited health literacy may improve outcomes and reduce disparities.
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Affiliation(s)
- Fatima Warsame
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christine E Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hao Ying
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Niraj M Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rasheeda K Hall
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Rekha Kambhampati
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tanjala S Purnell
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Sullivan CM, Barnswell KV, Greenway K, Kamps CM, Wilson D, Albert JM, Dolata J, Huml A, Pencak JA, Ducker JT, Gedaly R, Jones CM, Pesavento T, Sehgal AR. Impact of Navigators on First Visit to a Transplant Center, Waitlisting, and Kidney Transplantation: A Randomized, Controlled Trial. Clin J Am Soc Nephrol 2018; 13:1550-1555. [PMID: 30135171 PMCID: PMC6218827 DOI: 10.2215/cjn.03100318] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 06/22/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND OBJECTIVES Many patients with ESKD face barriers in completing the steps required to obtain a transplant. These eight sequential steps are medical suitability, interest in transplant, referral to a transplant center, first visit to center, transplant workup, successful candidate, waiting list or identify living donor, and receive transplant. This study sought to determine the effect of navigators on helping patients complete these steps. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Our study was a cluster randomized, controlled trial involving 40 hemodialysis facilities and four transplant centers in Ohio, Kentucky, and Indiana from January 1, 2014 to December 31, 2016. Four trained kidney transplant recipients met regularly with patients on hemodialysis at 20 intervention facilities, determined their step in the transplant process, and provided tailored information and assistance in completing that step and subsequent steps. Patients at 20 control facilities continued to receive usual care. Primary study outcomes were waiting list placement and receipt of a deceased or living donor transplant. An exploratory outcome was first visit to a transplant center. RESULTS Before the trial, intervention (1041 patients) and control (836 patients) groups were similar in the proportions of patients who made a first visit to a transplant center, were placed on a waiting list, and received a deceased or living donor transplant. At the end of the trial, intervention and control groups were also similar in first visit (16.1% versus 13.8%; difference, 2.3%; 95% confidence interval, -0.8% to 5.5%), waitlisting (16.3% versus 13.8%; difference, 2.5%; 95% confidence interval, -1.2% to 6.1%), deceased donor transplantation (2.8% versus 2.2%; difference, 0.6%; 95% confidence interval, -0.8% to 2.1%), and living donor transplantation (1.2% versus 1.0%; difference, 0.1%; 95% confidence interval, -0.9% to 1.1%). CONCLUSIONS Use of trained kidney transplant recipients as navigators did not increase first visits to a transplant center, waiting list placement, and receipt of deceased or living donor transplants.
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Affiliation(s)
| | | | - Kate Greenway
- Transplant Center, Ohio State University, Columbus, Ohio
| | - Cindy M. Kamps
- Transplant Center, University of Kentucky, Lexington, Kentucky
| | - Derrick Wilson
- Transplant Center, Lutheran Hospital, Fort Wayne, Indiana
| | | | | | - Anne Huml
- Center for Reducing Health Disparities and
- Division of Nephrology, University Hospitals, Cleveland, Ohio; and
- Division of Nephrology, MetroHealth Medical Center, Cleveland, Ohio
| | | | - John T. Ducker
- Transplant Center, Lutheran Hospital, Fort Wayne, Indiana
| | - Roberto Gedaly
- Transplant Center, University of Kentucky, Lexington, Kentucky
| | | | - Todd Pesavento
- Transplant Center, Ohio State University, Columbus, Ohio
| | - Ashwini R. Sehgal
- Center for Reducing Health Disparities and
- Departments of Population and Quantitative Health Sciences and
- Bioethics, Case Western Reserve University, Cleveland, Ohio
- Division of Nephrology, MetroHealth Medical Center, Cleveland, Ohio
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Knight RA. An Evolving Continuum of Care for the Kidney Disease Patient Will Help the Transplant Center Patient Navigator. Clin J Am Soc Nephrol 2018; 13:519-520. [PMID: 29581105 PMCID: PMC5968903 DOI: 10.2215/cjn.02300218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Richard A Knight
- College of Business, Department of Management, Marketing, and Public Administration, Bowie State University, Bowie, Maryland
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Waterman AD, Beaumont JL. What Else Can We Do to Ensure Transplant Equity for High-Risk Patients? Clin J Am Soc Nephrol 2018; 13:529-530. [PMID: 29581106 PMCID: PMC5969454 DOI: 10.2215/cjn.02120218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Amy D. Waterman
- Division of Nephrology, University of California, Los Angeles, California; and
- Terasaki Research Institute, Los Angeles, California
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