Culturally competent transplant program improves Hispanics' knowledge and attitudes about live kidney donation and transplant

Pragmatic strategies to address health disparities along the continuum of care in chronic liver disease

Racial, ethnic, and socioeconomic disparities exist in the prevalence and natural history of chronic liver disease, access to care, and clinical outcomes. Solutions to improve health equity range widely, from digital health tools to policy changes. The current review outlines the disparities along the chronic liver disease health care continuum from screening and diagnosis to the management of cirrhosis and considerations of pre-liver and post-liver transplantation. Using a health equity research and implementation science framework, we offer pragmatic strategies to address barriers to implementing high-quality equitable care for patients with chronic liver disease.

Expanding the access to kidney transplantation: Strategies for kidney transplant programs

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.

Neighborhood Segregation and Access to Live Donor Kidney Transplantation

Importance

Identifying the mechanisms of structural racism, such as racial and ethnic segregation, is a crucial first step in addressing the persistent disparities in access to live donor kidney transplantation (LDKT).

Objective

To assess whether segregation at the candidate's residential neighborhood and transplant center neighborhood is associated with access to LDKT.

Design, Setting, and Participants

In this cohort study spanning January 1995 to December 2021, participants included non-Hispanic Black or White adult candidates for first-time LDKT reported in the US national transplant registry. The median (IQR) follow-up time for each participant was 1.9 (0.6-3.0) years.

Main Outcome and Measures

Segregation, measured using the Theil H method to calculate segregation tertiles in zip code tabulation areas based on the American Community Survey 5-year estimates, reflects the heterogeneity in neighborhood racial and ethnic composition. To quantify the likelihood of LDKT by neighborhood segregation, cause-specific hazard models were adjusted for individual-level and neighborhood-level factors and included an interaction between segregation tertiles and race.

Results

Among 162 587 candidates for kidney transplant, the mean (SD) age was 51.6 (13.2) years, 65 141 (40.1%) were female, 80 023 (49.2%) were Black, and 82 564 (50.8%) were White. Among Black candidates, living in a high-segregation neighborhood was associated with 10% (adjusted hazard ratio [AHR], 0.90 [95% CI, 0.84-0.97]) lower access to LDKT relative to residence in low-segregation neighborhoods; no such association was observed among White candidates (P for interaction = .01). Both Black candidates (AHR, 0.94 [95% CI, 0.89-1.00]) and White candidates (AHR, 0.92 [95% CI, 0.88-0.97]) listed at transplant centers in high-segregation neighborhoods had lower access to LDKT relative to their counterparts listed at centers in low-segregation neighborhoods (P for interaction = .64). Within high-segregation transplant center neighborhoods, candidates listed at predominantly minority neighborhoods had 17% lower access to LDKT relative to candidates listed at predominantly White neighborhoods (AHR, 0.83 [95% CI, 0.75-0.92]). Black candidates residing in or listed at transplant centers in predominantly minority neighborhoods had significantly lower likelihood of LDKT relative to White candidates residing in or listed at transplant centers located in predominantly White neighborhoods (65% and 64%, respectively).

Conclusions

Segregated residential and transplant center neighborhoods likely serve as a mechanism of structural racism, contributing to persistent racial disparities in access to LDKT. To promote equitable access, studies should assess targeted interventions (eg, community outreach clinics) to improve support for potential candidates and donors and ultimately mitigate the effects of segregation.

Sikh and Muslim perspectives on kidney transplantation: phase 1 of the DiGiT project - a qualitative descriptive study

OBJECTIVES

Kidney transplantation offers patients better quality of life and survival compared with dialysis. The risk of end stage renal disease is higher among ethnic minorities and they experience longer wait times on transplant lists. This inequality stems from a high need for kidney transplantation combined with a low rate of deceased donation among ethnic minority groups. This study aimed to explore the perspectives around living donor kidney transplantation of members of the Sikh and Muslim communities with an aim to develop a digital intervention to overcome any barriers.

DESIGN

A qualitative descriptive study using in person focus groups.

SETTING

University Teaching Hospital and Transplant Centre.

PARTICIPANTS

Convenience sampling of participants from the transplant population. Three focus groups were held with 20 participants, all were of South Asian ethnicity belonging to the Sikh and Muslim communities.

METHODS

Interviews were digitally audio-recorded and transcribed verbatim; transcripts were analysed thematically.

RESULTS

Four themes were identified: (a) religious issues; (b) lack of knowledge within the community; (c) time; (d) cultural identification with transplantation.

CONCLUSIONS

Not only is the information given and when it is delivered important, but also the person giving the information is crucial to enhance consideration of live donor kidney transplantation. Information should be in a first language where possible and overtly align to religious considerations. A more integrated approach to transplantation counselling should be adopted which includes healthcare professionals and credible members of the target cultural group.

TRIAL REGISTRATION NUMBER

NCT04327167.

Knowledge About Renal Transplantation Among African, Caribbean, and Black Canadian Patients With Advanced Kidney Failure

Introduction

Variable transplant-related knowledge may contribute to inequitable access to living donor kidney transplant (LDKT). We compared transplant-related knowledge between African, Caribbean, and Black (ACB) versus White Canadian patients with kidney failure using the Knowledge Assessment of Renal Transplantation (KART) questionnaire.

Methods

This was a cross-sectional cohort study. Data were collected from a cross-sectional convenience sample of adults with kidney failure in Toronto. Participants also answered an exploratory question about their distrust in the kidney allocation system. Clinical characteristics were abstracted from medical records. The potential contribution of distrust to differences in transplant knowledge was assessed in mediation analysis.

Results

Among 577 participants (mean [SD] age 57 [14] years, 63% male), 25% were ACB, and 43% were White Canadians. 45% of ACB versus 26% of White participants scored in the lowest tertile of the KART score. The relative risk ratio to be in the lowest tertile for ACB compared to White participants was 2.22 (95% confidence interval [CI]: 1.11, 4.43) after multivariable adjustment. About half of the difference in the knowledge score between ACB versus White patients was mediated by distrust in the kidney allocation system.

Conclusion

Participants with kidney failure from ACB communities have less transplant-related knowledge compared to White participants. Distrust is potentially contributing to this difference.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Shared decision-making in advanced kidney disease: a scoping review

OBJECTIVES

To provide a comprehensive overview of interventions that support shared decision-making (SDM) for treatment modality decisions in advanced kidney disease (AKD). To provide summarised information on their content, use and reported results. To provide an overview of interventions currently under development or investigation.

DESIGN

The JBI methodology for scoping reviews was followed. This review conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist.

DATA SOURCES

MEDLINE, Embase, Web of Science, Cochrane Library, Emcare, PsycINFO, PROSPERO and Academic Search Premier for peer-reviewed literature. Other online databases (eg, clinicaltrials.gov, OpenGrey) for grey literature.

ELIGIBILITY FOR INCLUSION

Records in English with a study population of patients >18 years of age with an estimated glomerular filtration rate <30 mL/min/1.73 m². Records had to be on the subject of SDM, or explicitly mention that the intervention reported on could be used to support SDM for treatment modality decisions in AKD.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened and selected records for data extraction. Interventions were categorised as prognostic tools (PTs), educational programmes (EPs), patient decision aids (PtDAs) or multicomponent initiatives (MIs). Interventions were subsequently categorised based on the decisions they were developed to support.

RESULTS

One hundred forty-five interventions were identified in a total of 158 included records: 52 PTs, 51 EPs, 29 PtDAs and 13 MIs. Sixteen (n=16, 11%) were novel interventions currently under investigation. Forty-six (n=46, 35.7%) were reported to have been implemented in clinical practice. Sixty-seven (n=67, 51.9%) were evaluated for their effects on outcomes in the intended users.

CONCLUSION

There is no conclusive evidence on which intervention is the most efficacious in supporting SDM for treatment modality decisions in AKD. There is a lot of variation in selected outcomes, and the body of evidence is largely based on observational research. In addition, the effects of these interventions on SDM are under-reported.

Reducing disparities in kidney transplantation for Spanish-speaking patients through creation of a dedicated center

Introduction

Hispanic Americans receive disproportionately fewer organ transplants than non-Hispanic whites. In 2018, the Hispanic Kidney Transplant Program (HKTP) was established as at the University of Colorado Hospital (UCH). The purpose of this quality improvement study was to examine the effect of this culturally sensitive program in reducing disparities in kidney transplantation.

Methods

We performed a mixed-methods analysis of data from 436 Spanish-speaking patients referred for transplant to UCH between 2015 and 2020. We compared outcomes for patients referred between 2015–2017 (n = 156) to those referred between 2018–2020 (n = 280). Semi-structured phone interviews were conducted with 6 patients per time period and with 6 nephrology providers in the Denver Metro Area. Patients and providers were asked to evaluate communication, transplant education, and overall experience.

Results

When comparing the two time periods, there was a significant increase in the percentage of patients being referred (79.5% increase, p-0.008) and evaluated for transplant (82.4% increase, p = 0.02) during 2018–2020. While the number of committee reviews and number waitlisted increased during 2018–2020, it did not reach statistical significance (82.9% increase, p = 0.37 and 79.5% increase, p = 0.75, respectively. During patient and provider interviews, we identified 4 themes reflecting participation in the HKTP: improved communication, enhanced patient education, improved experience and areas for advancement. Overall, patients and providers reported a positive experience with the HKTP and noted improved patient understanding of the transplantation process.

Conclusions

The establishment of the HKTP is associated with a significant increase in Spanish-speaking Hispanic patients being referred and evaluated for kidney transplantation.

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

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

The Knowledge Assessment of Renal Transplantation (KART) 2.0: Development and Validation of CKD and Transplant Knowledge Scales

BACKGROUND AND OBJECTIVES

Many individuals with kidney disease, particularly those belonging to racial and ethnic minority groups and whose primary language is not English, lack knowledge related to kidney disease symptoms, physiologic functions of the kidney, and benefits and risks of kidney transplantation. Valid instruments to assess patients' knowledge of CKD and kidney transplantation are needed.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using a sample of 977 patients with stages 3-5 CKD in the Kaiser Permanente health system, we developed the Knowledge Assessment of Renal Transplantation (KART) 2.0 instrument. We conducted cognitive interviews followed by item response theory (IRT) to reduce 48 candidate items. Construct validity was tested by examining differences in scores between patients who spent <1 and ≥1 hour receiving CKD and transplant education.

RESULTS

Cognitive interviews modified four items and omitted 11. IRT analyses resulted in two scales: the KART 2.0-Transplant Knowledge Scale (16 items; Cronbach's α=0.8) and the KART 2.0-CKD Knowledge Scale (nine items; Cronbach's α=0.79). Differential item functioning showed that the scales were unbiased to capture knowledge across self-identified race, primary language, CKD stage, and sex. Both scales distinguished patients who had spent <1 and ≥1 hour speaking with health professionals (effect size [ES]=0.33 [transplant], 0.54 [CKD]; P<0.001 for both), reading about kidney disease (ES=0.45 [transplant], 0.62 [CKD]; P<0.001), reading about kidney transplantation (ES=0.67 [transplant], 0.69 [CKD]; P<0.001), and reading about living donor kidney transplant (ES=0.76 [transplant], 0.62 [CKD]; P<0.001).

CONCLUSIONS

The KART 2.0 is a valid tool to assess patients' knowledge of CKD and kidney transplantation.

Pretransplant Patient Education in Solid-organ Transplant: A Narrative Review

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.

Using Focus Groups to Understand Dialysis Staff Perspectives on Delivering Transplant Education

INTRODUCTION

Kidney transplant education in dialysis facilities could be optimized with internet resources, like videos, but most qualitative research predates widespread availability of online video education about kidney transplantation. To improve understanding of dialysis staff transplant education practices, as well as the potential value of video, we conducted focus groups of dialysis center staff members in Buffalo, NY.

METHODS/APPROACH

Seventeen focus groups (97 participants: 53 nurses, 10 dialysis technicians, 6 social workers, 6 dieticians, 7 administrative personnel, 2 trainees, and 1 insurance coordinator) from 8 dialysis facilities in Buffalo, NY, were conducted, audio-recorded, transcribed, and analyzed. After thematic data analysis, a diverse patient and caregiver community advisory board was invited to comment, and their voices were integrated. Findings: Five key themes were identified that captured barriers to transplant education delivery and how online video could be a facilitator: (1) delivery of transplant education was reliant on one person, (2) other dialysis staff had time to answer transplant questions but felt uninformed, (3) patient lack of interest in existing supplementary transplant education, (4) patient disinterest in transplantation education was due to education timing, feeling overwhelmed, and transplant fear/ambivalence, and (5) video education could be flexible, low effort, and spark transplant interest. Study limitations are potential selection bias and inclusion of English-speaking participants only.

DISCUSSION

Dialysis staff barriers of time, insufficient knowledge, and limited resources to provide education to patients and their care partners may be mitigated with online educational videos without increasing staff workload.

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

Hispanic patients receive disproportionately fewer living donor kidney transplants (LDKTs) than non-Hispanic Whites (NHWs). The Northwestern Medicine Hispanic Kidney Transplant Program (HKTP), designed to increase Hispanic LDKTs, was evaluated as a nonrandomized, implementation-effectiveness hybrid trial of patients initiating transplant evaluation at two intervention and two similar control sites. Using a mixed method, observational design, we evaluated the fidelity of the HKTP implementation at the two intervention sites. We tested the impact of the HKTP intervention by evaluating the likelihood of receiving LDKT comparing pre-intervention (January 2011-December 2016) and postintervention (January 2017-March 2020), across ethnicity and centers. The HKTP study included 2063 recipients. Intervention Site A exhibited greater implementation fidelity than intervention Site B. For Hispanic recipients at Site A, the likelihood of receiving LDKTs was significantly higher at postintervention compared with pre-intervention (odds ratio [OR] = 3.17 95% confidence interval [1.04, 9.63]), but not at the paired control Site C (OR = 1.02 [0.61, 1.71]). For Hispanic recipients at Site B, the likelihood of receiving an LDKT did not differ between pre- and postintervention (OR = 0.88 [0.40, 1.94]). The LDKT rate was significantly lower for Hispanics at paired control Site D (OR = 0.45 [0.28, 0.90]). The intervention significantly improved LDKT rates for Hispanic patients at the intervention site that implemented the intervention with greater fidelity. Registration: ClinicalTrials.gov registered (retrospectively) on September 7, 2017 (NCT03276390).

Development and Preliminary Evaluation of a Patient-facing Educational Video About Live Kidney Donor Surgical Complications

Background.

Living kidney donation (LKD) improves transplant access; however, its use is compromised, in part, by individuals’ unaddressed concerns about perioperative complications.

Methods.

We developed an animated, patient-centered educational video about LKD surgical complications, with input from experts in transplantation, communication, and anthropology, 35 patients/care partners (5 LKD candidates, 5 prior LKDs, 10 kidney transplant recipients, 10 kidney transplant candidates, 5 care partners), and 1 community advocate. We then conducted an online pre-post study with 24 potential kidney donors and recipients to measure the video’s acceptability and feasibility to improve donation complication knowledge and concerns.

Results.

Knowledge of LKD surgical complications increased 23% (mean 5.7 to 7.0, P < 0.01) from pre- to post- animation viewing. Large knowledge effect size increases were observed for different levels of age, race, health literacy, and technology access. The frequency of positive responses about donation safety increased from 88% preanimation to 96% postanimation. Concerns about surgical complications remained at 17% before and after exposure. After viewing the animation, over 90% indicated positive ratings on ease of watching, understanding, and engaging.

Conclusions.

An animated educational video about LKD surgical complications was developed in collaboration with multiple stakeholders. The video was well received and promised to positively impact individuals’ knowledge and concerns.

Knowledge and Attitudes Toward Renal Transplantation in Individuals Undergoing Transplant Evaluation

INTRODUCTION

The underutilization of kidney transplant as the preferred treatment for end-stage kidney disease is influenced by a lack of knowledge, poor attitudes, and various socio-demographic characteristics. Negative attitudes toward renal transplant disengage patients from the evaluation process and often hinder their likelihood of receiving a transplant.

PURPOSE

Determine whether a standardized educational session successfully improves knowledge and attitudes toward kidney transplant. Explore which socio-demographic variables are associated with more negative baseline attitude scores.

DESIGN

The program evaluation utilized a pre-test/post-test design to assess attitudes and knowledge toward renal transplant before and after an educational session. The pre- and post-surveys were distributed to a convenience sample of 341 and 115 patients, respectively, between the months of September and December 2019.

RESULTS

Exposure to a kidney transplant education program resulted in greater levels of knowledge (P = 0.019, d = 0.334). Individuals with no college education were found to have more negative baseline attitudes toward renal transplantation (P = 0.048, d = 0.382).

CONCLUSION

More research is needed to explore how knowledge, attitudes, and certain socio-demographic characteristics impact a patient's intention to pursue kidney transplant. Uncovering reasons as to why certain populations of individuals have more negative baseline attitudes toward kidney transplant may also provide clinicians and transplant programs with valuable information on how pre-transplant education can be tailored to meet the needs of specific populations.

Designing a Liver Transplant Patient and Family Decision Support Tool for Organ Offer Decisions

BACKGROUND

For liver transplant candidates on the waiting list, deciding to accept a donor organ with known or potential risk factors can be stressful and can lead to declined offers. Current education for patients and family often takes place during transplant evaluations and can be overwhelming and result in low retention and poor understanding of donor quality.

METHODS

In the first phase, we sought to understand provider experiences when counseling patients about donor risks and donor offers. We conducted interviews and focus groups with liver transplant providers at 1 local center and at a national clinician conference. Twenty providers participated: 15 hepatologists and 5 surgeons. The provider feedback was used to create an initial outline of content that is consistent with decision support frameworks. In a second phase, graphic design collaborators created mockups of a patient-friendly tool. We reviewed mockups with 4 transplant coordinators and 9 liver transplant candidates for feedback on clarity and utility to prepare for an organ offer. Patient responses allowed a comparison of perceived readiness to receive an offer call before and after viewing mockups.

RESULTS

We identified themes relating to the offer process, repetition and timing of education, and standardization and tailoring of content. The results indicated a gap in available education after the evaluation session, and information specific to offer decisions is needed. Patient feedback emphasized the need to review the offer process before a real offer.

CONCLUSIONS

Patients and providers responded favorably to a patient tool addressing existing gaps in education while waiting for a donor offer. Additional patient, family, and provider feedback will guide the development of an interactive tool to prepare patients and families for an offer decision.

Kidney Transplant Evaluation and Listing: Development and Preliminary Evaluation of Multimedia Education for Patients

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.

Financial Feasibility Analysis of a Culturally and Linguistically Competent Hispanic Kidney Transplant Program

BACKGROUND

In 2006, Northwestern Medicine implemented a culturally targeted and linguistically congruent Hispanic Kidney Transplant Program (HKTP). The HKTP has been associated with a reduction in Hispanic/Latino disparities in live donor kidney transplantation. This article assessed the financial feasibility of implementing the HKTP intervention at 2 other transplant centers.

METHODS

We examined the impact of the HKTP on staffing costs compared with the total transplant center costs using data from monthly time studies conducted among transplant staff involved in the HKTP. Time studies were conducted during the HKTP preimplementation (2016) and implementation (2017) phases. Labor costs were estimated using data from the time studies and mean salaries from the Department of Labor. We retrospectively examined kidney acquisition and transplant costs at both centers in 2016 and 2017 using data from the Medicare cost reports.

RESULTS

During preimplementation, center A staff (n = 21) committed 764 hours ($44 607), and center B staff (n = 15) committed 800 hours ($45 193) to establish the HKTP. During implementation, center A staff (n = 19) committed 1125 hours ($55 594), and center B staff (n = 24) committed 1396 hours ($64 170), in delivering the HKTP. Overall, the total costs from the staffing time involved in the HKTP encompassed <1.0% per year (2016 and 2017) of each center's annual total costs.

CONCLUSIONS

Our findings suggest the financial feasibility of implementing the HKTP and present a potential business case for the HKTP's implementation at other transplant centers to reduce health disparities in live donor kidney transplantation.

Your Path to Transplant: A randomized controlled trial of a tailored expert system intervention to increase knowledge, attitudes, and pursuit of kidney transplant

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.

Storytelling to Inspire Dialysis Patients to Learn about Living Donor Kidney Transplant

BACKGROUND

Policy changes including the Advancing American Kidney Health initiative and CMS's ESRD Quality Incentive Program recommend increasing educational initiatives within dialysis centers to increase living kidney donor transplant (LDKT) rates. LDKT education can be challenging in dialysis centers due to limited provider time to educate, patient fears or reluctance to learn about LDKT, and difficulty educating potential living donors. New educational innovations that increase dialysis patient curiosity about pursuing LDKT are needed.

SUMMARY

Digital first-person storytelling, or the sharing of narratives by individuals in their own words, is a culturally competent, health literate, patient-driven approach to expanding patient understanding about LDKT that can supplement traditional educational strategies without additional burden for dialysis providers. The Living Donation Storytelling Project is an online digital library of over 150 video stories told by diverse kidney recipients, donors, those in search of a donor, and their family/friends. By honestly discussing how they overcame fears and challenges related to LDKT, these stories address sensitive topics that can be hard for providers to introduce by using easily accessible learning methodology that may better connect with racial/ethnic minorities, scared patients, and patients facing health literacy challenges. Key Messages: Supplementing traditional educational approaches with digital storytelling may help overcome time limitations in educating for busy providers, boost providers' own knowledge about LDKT, serve as a free supplemental resource for patients, reduce fears and increase self-efficacy about transplant, help more patients to share about transplant with their social networks, and ultimately increase LDKT rates.

Analysis of Linguistically and Culturally Tailored Initiatives in Websites of Kidney Transplant Programs in the United States Between 2013-2018

INTRODUCTION

Minority patients constitute the majority of the kidney transplant waiting list, yet they suffer greater difficulties in listing and longer wait times to transplantation. There is a lack of information regarding targeted efforts by transplant centers to improve transplant care for minority populations.

RESEARCH QUESTION

Our aim was to analyze all kidney transplant websites in the United States to identify changes over a 5-year period in the number of multilingual websites, reported culturally targeted initiatives, and center and provider diversity.

DESIGN

Surveys were developed to analyze center websites of all transplant programs in the United States. Those with incomplete information about their nephrology or surgical teams were excluded, resulting in 174 (73%) sites in 2013 and 185 (76%) in 2018. Results: Few websites were available in a language other than English, 6.3% in 2013 and 9.7% in 2018 (P = 0.24). Only 3 websites (1.3%) in 2013 and 7 (3.7%) in 2018 reported any evidence of a culturally targeted initiative (P = 0.23). In 2018, 35% of centers employed a Hispanic transplant physician, 77% had a transplant physician who spoke a language other than English, and 39% had a transplant physician who spoke Spanish.

DISCUSSION

Although minority patients are expected to grow in the United States, decreased access to transplantation continues to vex the transplant community. Very little progress has been made in the development of multilingual websites and culturally targeted initiatives.

Efficacy of Educational Interventions in Improving Measures of Living-donor Kidney Transplantation Activity: A Systematic Review and Meta-analysis

BACKGROUND

To address patient-level barriers to living-donor kidney transplantation (LDKT), centers have implemented educational interventions. Recently, some have highlighted several gaps in knowledge and lack of evidence of efficacy of these interventions. No review has synthesized the available data.

METHODS

We conducted a systematic review and meta-analysis of studies conducted to increase measures of LDKT. Outcomes of interest were LDKT rates, donor evaluation, donor contact/inquiry, total transplantation rates, and change in knowledge scores and pursuit behaviors. A literature search was conducted across 7 databases from inception until 2017. Educational interventions were a decision/teaching aid alone or with personalized sessions. Comparator was another intervention or nonspecific education. Random effects meta-analysis was performed to pool risk ratios (RRs) across studies.

RESULTS

Of the 1813 references, 15 met the inclusion criteria; 9 were randomized control trials. When compared with nonspecific education, interventions increased LDKT rates (RR = 2.54; 95% confidence interval [CI], 1.49-4.35), donor evaluation (RR = 3.82; 95% CI, 1.91-7.64), and donor inquiry/contact (RR = 2.41; 95% CI, 1.53-3.80), but not total transplants (RR = 1.24; 95% CI, 0.96-1.61). Significant increased mean knowledge scores postintervention was noted, and most showed favorable trends in pursuit behaviors. Quality across the studies was mixed and sometimes difficult to assess. The biggest limitations were small sample size, selection bias, and short follow-ups.

CONCLUSIONS

Educational interventions improve measures of LDKT activity; however, current literature is heterogeneous and at risk of selection bias. Prospective studies with diverse patient populations, longer follow-ups, and robust outcomes are needed to inform clinical practice.

Patients' perceptions of a culturally targeted Hispanic Kidney Transplant Program: A mixed methods study

Disproportionately fewer waitlisted Hispanics receive living donor kidney transplants (LDKTs) compared to non-Hispanic whites. Northwestern Medicine's^® culturally targeted Hispanic Kidney Transplant Program (HKTP) is associated with a significant increase in LDKTs among Hispanics. This multisite study assessed potential kidney recipients' and donors' and/or family members' perceptions of the HKTP's cultural components through semi-structured interviews and validated surveys. Qualitative thematic analysis and descriptive statistics were performed. Thirty-six individuals participated (62% participation rate) comprising 21 potential recipients and 15 potential donors/family (mean age: 51 years, 50% female, 72% preferred Spanish). Participants felt confident about the educational information because a transplant physician delivered the education and viewed the group format as effective. Participants felt that education sessions addressed myths about transplantation shared by Hispanics. Primary use of Spanish enhanced participants' understanding of transplantation. While few knew about living donation before attending the HKTP, most were "more in favor of" kidney transplantation (97%) and living donation (97%) afterward. Few reported learning about the HKTP from outreach staff and suggested leveraging community leaders to promote HKTP awareness. Our findings suggest the HKTP's cultural components were viewed favorably and positively influenced perceptions of kidney transplantation and living donation, which may help reduce transplant disparities in Hispanics. (Clinicaltrial.gov registration # NCT03276390, date of registration: 9-7-17, retrospectively registered).

Attitudes of Latin American Immigrants Resident in Florida (United States) Toward Related Living Kidney Donation

INTRODUCTION

Latin American immigrants comprise an important population group in the United States. The purpose of this study was to analyze the attitude toward living kidney donation found among Latin American citizens who are residents in Florida and to identify the psychosocial variables affecting their attitude.

MATERIAL AND METHODS

A sample of Latin American residents in the state of Florida was randomly obtained and stratified by nationality, age, and sex (n = 1524). Attitude was assessed through a validated questionnaire that was self-administered and completed anonymously. Descriptive, Student t test and the χ² test were used to analyze findings.

RESULTS

The questionnaire completion rate was 94% (N = 1433), with 59% (n = 845) in favor of related living donation, 40% (n = 571) were opposed to donation, with the remaining 1% (n = 17) undecided. The following variables were related to attitude toward living donation: country of origin (P < .001), marital status (P < .001), having descendants (P = .004), educational background (P < 0.001), having had previous experience of donation and transplantation (P < .001), attitude toward deceased donation (P < .001), considering the possibility of needing a transplant (P < .001), the respondent's partner's opinion (P < .001), having considered the subject with one's family (P < .001), having carried out prosocial type activities (P < .001), the respondent's religion (P < .001), knowing that one's religion is in favor of this therapy (P < .001), concern about mutilation after donation (P < .001), and considerations of the risks of living donation (P < .001).

CONCLUSIONS

The attitude toward related living kidney donation of Latin American residents in Florida is not very favorable (only 59%).

Differences in Attitudes Toward Living Kidney Donation Among Dominican Immigrants Living in Spain and the United States

BACKGROUND

The Dominican population has a double-emigration pathway: one is to the USA, by proximity, and the other is to Spain, by sociocultural identification. Our aim was to determine attitudes toward living organ donation among Dominicans residing in Florida (USA) and Spain.

METHODS

All study participants were at least 15 years old and living in either Florida (USA) or Spain, and stratified by gender and age. A questionnaire on attitudes toward living kidney donation ("PCID-LKD Ríos") was used. The support of immigrant associations in Florida and Spain was required to advise on survey locations. Data obtained were anonymized and self-administered.

RESULTS

The study questionnaire was completed by 123 Dominicans, 68% of whom were in favor of living related kidney donation. There were differences (P = .004) according to the country of residence. Eighty-one percent of Spain's Dominican residents were in favor, compared with 56% of Florida's residents. Factors associated with attitude toward donation were level of education (P < .001), previous experience with organ donation (P = .006), attitude toward cadaveric organ donation (P < .001), belief in the possibility of needing a transplant in the future (P = .016), discussing the issue with one's family (P = .007), discussing the issue with husband/wife/partner (P = .002), carrying out pro-social activities (P = .029), religious beliefs (P = .001), and understanding the risk of living kidney donation (P = .046).

CONCLUSION

Attitudes toward living kidney donation among immigrant Dominicans varies between Spain and the USA, with the former showing a more positive view.

A complex culturally targeted intervention to reduce Hispanic disparities in living kidney donor transplantation: an effectiveness-implementation hybrid study protocol

BACKGROUND

The shortage of organs for kidney transplantation for patients with end-stage renal disease (ESRD) is magnified in Hispanics/Latin Americans in the United States. Living donor kidney transplantation (LDKT) is the treatment of choice for ESRD. However, compared to their representation on the transplant waitlist, fewer Hispanics receive a LDKT than non-Hispanic whites. Barriers to LDKT for Hispanics include: lack of knowledge, cultural concerns, and language barriers. Few interventions have been designed to reduce LDKT disparities. This study aims to reduce Hispanic disparities in LDKT through a culturally targeted intervention.

METHODS/DESIGN

Using a prospective effectiveness-implementation hybrid design involving pre-post intervention evaluation with matched controls, we will implement a complex culturally targeted intervention at two transplant centers in Dallas, TX and Phoenix, AZ. The goal of the study is to evaluate the effect of Northwestern Medicine's® Hispanic Kidney Transplant Program's (HKTP) key culturally targeted components (outreach, communication, education) on Hispanic LDKT rates over five years. The main hypothesis is that exposure to the HKTP will reduce disparities by increasing the ratio of Hispanic to non-Hispanic white LDKTs and the number of Hispanic LDKTs. We will also examine other process and outcome measures including: dialysis patient outreach, education session attendance, marketing efforts, Hispanic patients added to the waitlist, Hispanic potential donors per potential recipient, and satisfaction with culturally competent care. We will use mixed methods based on the Promoting Action on Research Implementation in Health Services (revised PARIHS) and the Consolidated Framework for Implementation Research (CFIR) frameworks to formatively evaluate the fidelity and innovative adaptations to HKTP's components at both study sites, to identify moderating factors that most affect implementation fidelity, and to identify adaptations that positively and negatively affect outcomes for patients.

DISCUSSION

Our study will provide new knowledge about implementing culturally targeted interventions and their impact on reducing health disparities. Moreover, the study of a complex organizational-level intervention's implementation over five years is rare in implementation science; as such, this study is poised to contribute new knowledge to the factors influencing how organizational-level interventions are sustained over time.

TRIAL REGISTRATION

(ClinicalTrials.gov registration # NCT03276390 , date of registration: 9-7-17, retrospectively registered).

Strategies for Increasing Knowledge, Communication, and Access to Living Donor Transplantation: an Evidence Review to Inform Patient Education

Purpose of review

Inadequate knowledge of the benefits, risks and opportunities for living donation is an important, potentially modifiable barrier to living donor transplantation. We assessed the current state of the evidence regarding strategies to increase knowledge, communication and access to living donor transplantation, as reported in peer-reviewed medical literature.

Recent Findings

Nineteen studies were reviewed, categorized as programs evaluated in randomized controlled trials (8 studies) and programs supported by observational (non-randomized) studies (11 studies). Content extraction demonstrated that comprehensive education about living donation and living donor transplantation involves multiple learners - the transplant candidate, potential living donors, and social support networks - and requires communicating complex information about the risks and benefits of donation, transplantation and alternative therapies to these different audiences. Transplant centers can help transplant patients learn about living donor transplantation through a variety of formats and modalities, including center-based, home-based and remote technology-based education, outreach to dialysis centers, and social media. Evaluation of these strategies and program themes informed a new Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) public education brochure.

Summary

Increasing transplant candidate knowledge and comfort in talking about living donation and transplantation can reduce educational barriers to pursuit of living donor transplants. Ongoing efforts are needed to develop, refine and disseminate educational programs to help improve transplant access for more patients in need of organ donors.

Association of Race and Ethnicity With Live Donor Kidney Transplantation in the United States From 1995 to 2014

IMPORTANCE

Over the past 2 decades, there has been increased attention and effort to reduce disparities in live donor kidney transplantation (LDKT) for black, Hispanic, and Asian patients with end-stage kidney disease. The goal of this study was to investigate whether these efforts have been successful.

OBJECTIVE

To estimate changes over time in racial/ethnic disparities in LDKT in the United States, accounting for differences in death and deceased donor kidney transplantation.

DESIGN, SETTING, AND PARTICIPANTS

A secondary analysis of a prospectively maintained cohort study conducted in the United States of 453 162 adult first-time kidney transplantation candidates included in the Scientific Registry of Transplant Recipients between January 1, 1995, and December 31, 2014, with follow-up through December 31, 2016.

EXPOSURES

Race/ethnicity.

MAIN OUTCOMES AND MEASURES

The primary study outcome was time to LDKT. Multivariable Cox proportional hazards and competing risk models were constructed to assess changes in racial/ethnic disparities in LDKT among adults on the deceased donor kidney transplantation waiting list and interaction terms were used to test the statistical significance of temporal changes in racial/ethnic differences in receipt of LDKT. The adjusted subhazard ratios are estimates derived from the multivariable competing risk models. Data were categorized into 5-year increments (1995-1999, 2000-2004, 2005-2009, 2010-2014) to allow for an adequate sample size in each analytical cell.

RESULTS

Among 453 162 adult kidney transplantation candidates (mean [SD] age, 50.9 [13.1] years; 39% were women; 48% were white; 30%, black; 16%, Hispanic; and 6%, Asian), 59 516 (13.1%) received LDKT. Overall, there were 39 509 LDKTs among white patients, 8926 among black patients, 8357 among Hispanic patients, and 2724 among Asian patients. In 1995, the cumulative incidence of LDKT at 2 years after appearing on the waiting list was 7.0% among white patients, 3.4% among black patients, 6.8% among Hispanic patients, and 5.1% among Asian patients. In 2014, the cumulative incidence of LDKT was 11.4% among white patients, 2.9% among black patients, 5.9% among Hispanic patients, and 5.6% among Asian patients. From 1995-1999 to 2010-2014, racial/ethnic disparities in the receipt of LDKT increased (P < .001 for all statistical interaction terms in adjusted models comparing white patients vs black, Hispanic, and Asian patients). In 1995-1999, compared with receipt of LDKT among white patients, the adjusted subhazard ratio was 0.45 (95% CI, 0.42-0.48) among black patients, 0.83 (95% CI, 0.77-0.88) among Hispanic patients, and 0.56 (95% CI, 0.50-0.63) among Asian patients. In 2010-2014, compared with receipt of LDKT among white patients, the adjusted subhazard ratio was 0.27 (95% CI, 0.26-0.28) among black patients, 0.52 (95% CI, 0.50-0.54) among Hispanic patients, and 0.42 (95% CI, 0.39-0.45) among Asian patients.

CONCLUSIONS AND RELEVANCE

Among adult first-time kidney transplantation candidates in the United States who were added to the deceased donor kidney transplantation waiting list between 1995 and 2014, disparities in the receipt of live donor kidney transplantation increased from 1995-1999 to 2010-2014. These findings suggest that national strategies for addressing disparities in receipt of live donor kidney transplantation should be revisited.

Racial/Ethnic Differences in Barriers to Kidney Transplant Evaluation among Hemodialysis Patients

BACKGROUND

Only a small percentage of dialysis patients receive a transplant and this is particularly the case for racial/ethnic minorities. Our objective was to identify barriers to initial transplant evaluation in our dialysis centers.

METHODS

We conducted a survey of adult hemodialysis patients from 4 dialysis units in the Denver Metro area in 2016. Participants completed an 11-item survey with demographic information and questions regarding time on dialysis, if a provider ever spoke to them about transplant, and whether they had been evaluated for a transplant. Reasons for not having an evaluation were explored. Descriptive statistics, chi-square analyses, and multivariate analyses were used to examine the responses.

RESULTS

A total of 167 patients completed the survey (response rate 63.9%). The majority of participants were male and were Hispanic (49%) or Non-Hispanic black (31.7%). Of these, 140 patients (84.0%) reported discussing kidney transplantation with their doctor but only 53% reported having a transplant evaluation. After adjustment for age, gender, and time on dialysis, significantly fewer blacks reported having an evaluation than Non-Hispanic whites or Hispanics (43.4 vs. 57.7% [whites] and 59.7% [Hispanics], p = 0.03). The most frequent responses of the patients who had not been evaluated were the following: not referred by their provider (46%), did not know how to proceed (43.4%), or did not understand the benefits (39.5%) or transplant process (38.2%). Compared to Non-Hispanic whites, blacks and Hispanics reported less understanding of the benefits and process of transplant.

CONCLUSION

Timely referral by providers and improved kidney transplantation education may reduce disparities in access to kidney transplantation.

Difficult conversations: Australian Indigenous patients' views on kidney transplantation

Background

Indigenous Australians suffer a disproportionate burden of end stage kidney disease (ESKD) but are significantly less likely to receive a transplant. This study explores Indigenous ESKD patients’ views on transplantation as a treatment option.

Methods

The Improving Access to Kidney Transplants (IMPAKT) research program investigated barriers to kidney transplantation for Indigenous Australians. An interview study, conducted in 2005–2006, elicited illness experience narratives from 146 Indigenous patients, including views on transplant. Interviews were conducted at 26 sites that collectively treat the majority of Indigenous ESKD patients. Key themes were identified via team consensus meetings, providing a flexible framework and focus for continued coding.

Results

Four inter-related themes were identified in patient commentary: a very high level (90% of respondents) of positive interest in transplantation; patients experienced a range of communication difficulties and felt uninformed about transplant; family involvement in decision-making was constrained by inadequate information; and patients needed to negotiate cultural and social sensitivities around transplantation.

Conclusions

Indigenous ESKD patients demonstrated an intense interest in transplantation preferring deceased over living kidney donation. Patients believe transplant is the path most likely to support the re-establishment of their ‘normal’ family life. Patients described themselves as poorly informed; most had only a rudimentary knowledge of the notion of transplant but no understanding of eligibility criteria, the transplant procedure and associated risks. Patients experienced multiple communication barriers that - taken together - undermine their engagement in treatment decision-making. Families and communities are disempowered because they also lack information to reach a shared understanding of transplantation. Cultural sensitivities associated with transplantation were described but these did not appear to constrain patients in making choices about their own health.

Transplant units and local treatment providers should collaborate to develop user-friendly, culturally informed and region-specific patient education programs. Quality improvement cycles should underpin the development of national guidelines for patient education.

Noting Indigenous patients’ intense interest in transplantation, and nephrologists’ concerns regarding poor transplant outcomes, research should prioritise exploring the predictors of transplant outcomes for Indigenous Australians.

Electronic supplementary material

The online version of this article (10.1186/s12882-017-0726-z) contains supplementary material, which is available to authorized users.

A Culturally Targeted Website for Hispanics/Latinos About Living Kidney Donation and Transplantation: A Randomized Controlled Trial of Increased Knowledge

BACKGROUND

Hispanics/Latinos receive disproportionately fewer living donor kidney transplantations (LDKTs) than non-Hispanic whites. We conducted a multisite, randomized controlled trial to evaluate the efficacy of exposure to a bilingual, culturally targeted website, Infórmate, for increasing Hispanics' knowledge about LDKT.

METHODS

Hispanic patients initiating transplant evaluation and their family/friends at 2 transplant centers were randomized to view Infórmate before attending routine transplant education sessions; usual care controls only attended education sessions. All participants completed a pretest; website participants also completed a posttest immediately after viewing Infórmate. All participants completed a 3-week telephone follow-up test. Random effects linear regression of 3-week knowledge scores tested the significance of website exposure after adjusting for clustering within families and controlling for pretest scores and covariates.

RESULTS

Two hundred-eighty-two individuals participated (81% patient participation rate). Website exposure was associated with a mean 21.7% same day knowledge score increase between pretest and posttest (P < 0.001). At 3 weeks, website participants' knowledge scores remained 22.6% above the pretest; control scores increased to 11.8% (P = 0.0001). Regression results found that website participants were associated with a 10.0% greater knowledge score at 3-week follow-up (P < 0.0001). Most website participants (92.6%) plan to return to Infórmate in the future.

CONCLUSIONS

Our culturally targeted website increased participants' knowledge about LDKT above and beyond transplant education and should supplement transplant center education for Hispanics. When considered at the population level, Infórmate could have a great impact on knowledge gains in this underserved population disproportionately affected by kidney disease.

Living Organ Donation and Informed Consent in the United States: Strategies to Improve the Process

About 6,000 individuals participate in the U.S. transplant system as a living organ donor each year. Organ donation (most commonly a kidney or part of liver) by living individuals is a unique procedure, where healthy patients undergo a major surgical operation without any direct functional benefit to themselves. In this article, the authors explore how the ideal of informed consent guides education and evaluation for living organ donation. The authors posit that informed consent for living organ donation is a process. Though the steps in this process are partially standardized through national health policy, they can be improved through institutional structures at the local, transplant center-level. Effective structures and practices aimed at supporting and promoting comprehensive informed consent provide more opportunities for candidates to ask questions about the risks and benefits of living donation and to opt out voluntarily Additionally, these practices could enable new ways of measuring knowledge and improving the consent process.

Communicating About Choices in Transplantation (COACH)

Introduction:

Previous research highlights the difficulties patients with end-stage renal disease awaiting kidney transplant experience while attempting to manage both the logistical and the content-related aspects of discussions about transplantation. This article presents pilot results of the behavioral communication intervention program, Communicating about Choices in Transplantation (COACH), designed to improve transplant candidates’ communication about transplantation.

Research Questions:

As compared to matched controls, increases in knowledge of deceased and living donor transplantation, communication self-efficacy, intentions to hold conversations about transplantation, and self-reported discussion were expected for pilot participants from pre- and postassessment; decreases in conversational difficulties were also posited.

Design:

Using a nonrandomized quasi-experimental design, we compared transplant knowledge and communication between patients completing a 2-hour COACH session (pilot sample) to a sample of matched controls (n = 10). Data were collected via semi-structured telephone interviews upon enrollment and 1 month after enrollment or attendance at a COACH program session.

Results:

The results revealed significant differences in knowledge from pre- to postassessment between the pilot and control samples ( P = .02). Although no other statistically significant between-group differences were found, paired-sample t tests revealed significant pre–post increases in transplant knowledge (7.6 [standard deviation, SD = 2.0] to 9.5 [SD =1.8]; P = .05) and communication self-efficacy (1255.8 [SD = 239.7] to 1513.8 [SD = 114.3]; P = .009) for pilot participants. Decreases in perceived conversational difficulties were also observed ( P = .53).

Discussion:

Results provide preliminary support for the program’s impact. Moreover, participant evaluations of the COACH were overwhelmingly positive. A more definitive program evaluation with a larger, more diverse sample is currently underway.

A Website Intervention to Increase Knowledge About Living Kidney Donation and Transplantation Among Hispanic/Latino Dialysis Patients

BACKGROUND

Hispanic dialysis patients often encounter barriers to learning about living kidney donation and transplantation. Effective culturally targeted interventions to increase knowledge are lacking. We developed a culturally targeted educational website to enhance informed treatment decision making for end-stage kidney disease.

METHODS

A pretest/posttest intervention study was conducted among adult Hispanic patients undergoing dialysis at 5 dialysis centers in Chicago, Illinois. Surveys included a 31-item, multiple-choice pretest/posttest of knowledge about kidney transplantation and living donation, attitudes about the website, Internet use, and demographics. The intervention entailed viewing 3 of 6 website sections for a total of 30 minutes. The pretest/posttest was administered immediately before and after the intervention. Participants completed a second posttest via telephone 3 weeks thereafter to assess knowledge retention, attitudes, and use of the website.

RESULTS

Sixty-three patients participated (96% participation rate). Website exposure was associated with a mean 17.1% same day knowledge score increase between pretest and posttest (P < .001). At 3 weeks, participants' knowledge scores remained 11.7% above pretest (P < .001). The greatest knowledge gain from pretest to 3-week follow-up occurred in the Treatment Options (P < .0001) and Cultural Beliefs and Myths (P < .0001) website sections. Most participants (95%) "agreed" or "strongly agreed" that they would recommend the website to other Hispanics.

CONCLUSIONS

Web-based education for patients undergoing dialysis can effectively increase Hispanics' knowledge about transplantation and living kidney donation. Study limitations include small sample size and single geographic region study. Dialysis facilities could enable website access as a method of satisfying policy requirements to provide education about kidney transplantation.

The Potential (F)utility of a Passive Organ Donor Registration Opportunity: A Conceptual Replication

CONTEXT

Approximately 22 people die each day in the United States as a result of the shortage of transplantable organs. This is particularly problematic among Spanish-dominant Hispanics. Increasing the number of registered organ donors can reduce this deficit.

OBJECTIVE

The goal of the current set of studies was to conceptually replicate a prior study indicating the lack of utility of a lone, immediate and complete registration opportunity (ICRO).

DESIGN AND SETTING

The study, a quasi-experimental design involving a total of 4 waves of data collection, was conducted in 2 different Mexican consulates in the United States. Guided by the IIFF Model (ie, an ICRO, information, focused engagement, and favorable activation), each wave compared a lone ICRO to a condition that likewise included an ICRO but also included the 3 additional intervention components recommended by the model (ie, information, focused engagement, and favorable activation).

PARTICIPANTS

Visitors to the Mexican consulates in Tucson, Arizona, and Albuquerque, New Mexico, constituted the participant pool.

MAIN OUTCOME MEASURE

New organ donor registrations represented the dependent variable.

RESULTS

When all 4 components of the IIFF Model were present, approximately 4 registrations per day were recorded; the lone ICRO resulted in approximately 1 registration every 15 days.

CONCLUSION

An ICRO, without the other components of the IIFF Model, is of minimal use in regard to garnering organ donor registrations. Future studies should use the IIFF Model to consider how the utility of ICROs can be maximized.

Association of Candidate Removals From the Kidney Transplant Waiting List and Center Performance Oversight

Approximately 59 000 kidney transplant candidates have been removed from the waiting list since 2000 for reasons other than transplantation, death, or transfers. Prior studies indicate that low-performance (LP) center evaluations by the Scientific Registry of Transplant Recipients (SRTR) are associated with reductions in transplant volume. There is limited information to determine whether performance oversight impacts waitlist management. We used national SRTR data to evaluate outcomes of 315 796 candidates on the kidney transplant waiting list (2007-2014). Compared to centers without LP, rates of waitlist removal (WLR) were higher at centers with LP evaluations (44.6/1000 follow-up years, 95% confidence interval [CI] 44.0, 45.1 versus 68.0/1000 follow-up years, 95% CI 66.6, 69.4), respectively, which was consistent after risk adjustment (adjusted hazard ratio [AHR] = 1.59, 95% CI 1.55, 1.63). Candidate mortality following waitlist removal was lower at LP centers (AHR = 0.90, 95% CI 0.87, 0.94). Analyses limited to LP centers indicated a significant increase in WLR (+28.6 removals/1000 follow-up years, p < 0.001), a decrease in transplant rates (-11.9/1000 follow-up years, p < 0.001) and a decrease in mortality after removal (-67.5 deaths/1000 follow-up years, p < 0.001) following LP evaluation. There is a significant association between LP evaluations and transplant center processes of care for waitlisted candidates. Further understanding is needed to determine the impact of performance oversight on transplant center quality of care and patient outcomes.

Educating Prospective Kidney Transplant Recipients and Living Donors about Living Donation: Practical and Theoretical Recommendations for Increasing Living Donation Rates

A promising strategy for increasing living donor kidney transplant (LDKT) rates is improving education about living donation for both prospective kidney transplant recipients and living donors to help overcome the proven knowledge, psychological, and socioeconomic barriers to LDKT. A recent Consensus Conference on Best Practices in Live Kidney Donation recommended that comprehensive LDKT education be made available to patients at all stages of chronic kidney disease (CKD). However, in considering how to implement this recommendation across different healthcare learning environments, the current lack of available guidance regarding how to design, deliver, and measure the efficacy of LDKT education programs is notable. In the current article, we provide an overview of how one behavior change theory, the Transtheoretical Model of Behavior Change, can guide the delivery of LDKT education for patients at various stages of CKD and readiness for LDKT. We also discuss the importance of creating educational programs for both potential kidney transplant recipients and living donors, and identify key priorities for educational research to reduce racial disparities in LDKT and increase LDKT rates.

Hispanic/Latino Disparities in Living Donor Kidney Transplantation: Role of a Culturally Competent Transplant Program

Hispanic Americans face disparities in access to kidney transplantation, particularly living donor kidney transplantation (LDKT). This study compared characteristics of LDKT recipients before and after implementing the Hispanic Kidney Transplant Program (HKTP) at Northwestern Medicines (NM) and other centers.

METHODS

The NM HKTP, initiated in December 2006, delivers culturally and linguistically competent and congruent care. Program-specific data were used to compare the mean ratios of Hispanic to non-Hispanic white LDKTs between pre-HKTP (2001-2006) and post-HKTP (2008-2013), and to compare the characteristics of NM's adult LDKT patients between pre-HKTP and post-HKTP. The same ratio was calculated for transplant centers in regions with a significant Hispanic population (≥25%) and performing in the top tertile of total LDKT volume in the pre-HKTP period. The number of Hispanic and non-Hispanic white patients added to the waiting list were compared between pre-HKTP (2001-2006) and post-HKTP (2008-2013) as a proxy for increased patient referrals and a pathway by which the HKTP may increase LDKTs.

RESULTS

The ratio of Hispanic to non-Hispanic white LDKTs significantly increased by 70% after the implementation of NM's HKTP (pre-HKTP mean = 0.20, post-HKTP mean = 0.34; P= 0.001). None of the other transplant centers experienced a similar increase in their ratio of Hispanic to non-Hispanic white LDKTs. The NM waiting list additions grew by 91% among Hispanics, but grew only 4% for non-Hispanic whites.

CONCLUSIONS

These data suggest that the development and implementation of a culturally congruent transplant program can positively affect Hispanic LDKT and thereby reduce Hispanics disparities in LDKT rates. Further studies are needed to prospectively evaluate the generalizability of implementing such culturally competent interventions at other transplant programs.

Explore Transplant at Home: a randomized control trial of an educational intervention to increase transplant knowledge for Black and White socioeconomically disadvantaged dialysis patients

BACKGROUND

Compared to others, dialysis patients who are socioeconomically disadvantaged or Black are less likely to receive education about deceased donor kidney transplant (DDKT) and living donor kidney transplant (LDKT) before they reach transplant centers, often due to limited availability of transplant education within dialysis centers. Since these patients are often less knowledgeable or ready to pursue transplant, educational content must be simplified, made culturally sensitive, and presented gradually across multiple sessions to increase learning and honor where they are in their decision-making about transplant. The Explore Transplant at Home (ETH) program was developed to help patients learn more about DDKT and LDKT at home, with and without telephone conversations with an educator.

METHODS AND STUDY DESIGN

In this randomized controlled trial (RCT), 540 low-income Black and White dialysis patients with household incomes at or below 250 % of the federal poverty line, some of whom receive financial assistance from the Missouri Kidney Program, will be randomly assigned to one of three education conditions: (1) standard-of-care transplant education provided by the dialysis center, (2) patient-guided ETH (ETH-PG), and (3) health educator-guided ETH (ETH-EG). Patients in the standard-of-care condition will only receive education provided in their dialysis centers. Those in the two ETH conditions will receive four video and print modules delivered over an 8 month period by mail, with the option of receiving supplementary text messages weekly. In addition, patients in the ETH-EG condition will participate in multiple telephonic educational sessions with a health educator. Changes in transplant knowledge, decisional balance, self-efficacy, and informed decision making will be captured with surveys administered before and after the ETH education.

DISCUSSION

At the conclusion of this RCT, we will have determined whether an education program administered to socioeconomically disadvantaged dialysis patients, over several months directly in their homes, can help more individuals learn about the options of DDKT and LDKT. We also will be able to examine the efficacy of different educational delivery approaches to further understand whether the addition of a telephone educator is necessary for increasing transplant knowledge.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02268682.

An overview of disparities and interventions in pediatric kidney transplantation worldwide

Despite the stated goals of the transplant community and the majority of organ allocation systems, persistent racial disparities in pediatric kidney transplantation exist throughout the world. These disparities are evident in both living and deceased donor kidney transplantation and are independent of any clinical differences between racial groups. The reasons for these persistent disparities are multifactorial, reflecting both patient and provider barriers to care. In this review, we examine the most current findings regarding disparities in pediatric kidney transplantation and consider interventions which may help reduce those disparities.

An interactive, bilingual, culturally targeted website about living kidney donation and transplantation for hispanics: development and formative evaluation

Background

As the kidney shortage continues to grow, patients on the waitlist are increasingly turning to live kidney donors for transplantation. Despite having a disproportionately higher prevalence of end-stage kidney disease (ESKD), fewer waitlisted Hispanic patients received living donor kidney transplants (LDKTs) than non-Hispanic whites in 2014. Although lack of knowledge has been identified as a barrier to living kidney donation (LKD) among Hispanics, little is known about information needs, and few bilingual educational resources provide transplant-related information addressing Hispanics’ specific concerns.

Objective

This paper describes the process of developing a bilingual website targeted to the Hispanic community. The website was designed to increase knowledge about LKD among Hispanic patients with ESKD, their families, and the public, and was inspired by educational sessions targeted to Hispanic transplant patients provided by Northwestern University’s Hispanic Kidney Transplant Program.

Methods

Northwestern faculty partnered with the National Kidney Foundation of Illinois for expertise in ESKD and Hispanic community partners across the Chicago area. We established a Community Advisory Board (CAB) of 10 Chicago-area Hispanic community leaders to provide insight into cultural concerns and community and patients’ needs. Website content development was informed by 9 focus groups with 76 adult Hispanic kidney transplant recipients, living kidney donors, dialysis patients, and the general Hispanic public. The website development effort was guided by community input on images, telenovela scripts, and messages. After initial development, formal usability testing was conducted with 18 adult Hispanic kidney transplant recipients, dialysis patients, and living kidney donors to identify ways to improve navigability, design, content, comprehension, and cultural sensitivity. Usability testing revealed consistently high ratings as “easy to navigate”, “informative”, and “culturally appropriate”. Bandura’s Social Cognitive Theory and Gagne’s Conditions of Learning Theory guided website design to facilitate adult learning.

Results

The website, “Infórmate: Living Kidney Donation for Hispanics/Latinos” (Infórmate Acerca de la Donación de Riñón en Vida), includes six sections: Treatment Options, Donation: Step-by-Step, Benefits and Risks, Financial Issues, Immigrant Issues, and Cultural Beliefs and Myths. Sections host 5-10 interactive messages that summarize important points and link to detailed explanations for users interested in learning more about specific issues. The website hosts interactive videos, multimedia testimonials, telenovelas, games, and quizzes. Photographs and videos of Hispanic living donors are shown to promote pride and ownership.

Conclusions

Our success in developing a website was driven by a development team with expertise in transplantation, social science, evaluation, instructional design, and Hispanic perspectives, and by a patient-centered approach toward content and design. Based on feedback from usability testing and our CAB, the website is sensitive to Hispanic cultural sensibilities. We have nearly completed a formal evaluation of the website’s impact on increasing Hispanics’ knowledge about LKD and will disseminate the website thereafter.

Living Donor Kidney Transplantation: Overcoming Disparities in Live Kidney Donation in the US--Recommendations from a Consensus Conference

Despite its superior outcomes relative to chronic dialysis and deceased donor kidney transplantation, live donor kidney transplantation (LDKT) is less likely to occur in minorities, older adults, and poor patients than in those who are white, younger, and have higher household income. In addition, there is considerable geographic variability in LDKT rates. Concomitantly, in recent years, the rate of living kidney donation (LKD) has stopped increasing and is declining, after decades of consistent growth. Particularly noteworthy is the decline in LKD among black, younger, male, and lower-income adults. The Live Donor Community of Practice within the American Society of Transplantation, with financial support from 10 other organizations, held a Consensus Conference on Best Practices in Live Kidney Donation in June 2014. The purpose of this meeting was to identify LKD best practices and knowledge gaps that might influence LDKT, with a focus on patient and donor education, evaluation efficiencies, disparities, and systemic barriers to LKD. In this article, we discuss trends in LDKT/LKD and emerging novel strategies for attenuating disparities, and we offer specific recommendations for future clinical practice, education, research, and policy from the Consensus Conference Workgroup focused on disparities.