A Randomized Trial to Reduce Disparities in Referral for Transplant Evaluation

Abstract

Georgia has the lowest kidney transplant rates in the United States and substantial racial disparities in transplantation. We determined the effectiveness of a multicomponent intervention to increase referral of patients on dialysis for transplant evaluation in the Reducing Disparities in Access to kidNey Transplantation Community Study (RaDIANT), a randomized, dialysis facility-based, controlled trial involving >9000 patients receiving dialysis from 134 dialysis facilities in Georgia. In December of 2013, we selected dialysis facilities with either low transplant referral or racial disparity in referral. The intervention consisted of transplant education and engagement activities targeting dialysis facility leadership, staff, and patients conducted from January to December of 2014. We examined the proportion of patients with prevalent ESRD in each facility referred for transplant within 1 year as the primary outcome, and disparity in the referral of black and white patients as a secondary outcome. Compared with control facilities, intervention facilities referred a higher proportion of patients for transplant at 12 months (adjusted mean difference [aMD], 7.3%; 95% confidence interval [95% CI], 5.5% to 9.2%; odds ratio, 1.75; 95% CI, 1.36 to 2.26). The difference between intervention and control facilities in the proportion of patients referred for transplant was higher among black patients (aMD, 6.4%; 95% CI, 4.3% to 8.6%) than white patients (aMD, 3.7%; 95% CI, 1.6% to 5.9%; <0.05). In conclusion, this intervention increased referral and improved equity in kidney transplant referral for patients on dialysis in Georgia; long-term follow-up is needed to determine whether these effects led to more transplants.

Standardized Transplantation Referral Ratio to Assess Performance of Transplant Referral among Dialysis Facilities

“…Although national transplant referral data are unavailable, we recently collected patient referral data from all Georgia transplant centers as part of the Reducing Disparities in Access to Kidney Transplantation Community Study, and an extension of this data collection in other states is underway (13). The few studies that have examined transplant performance using transplant referral have used facility-level absolute referral rate to measure facility performance (3,14,15). In a recent study, we examined whether absolute facility referral was associated with other quality metrics within dialysis facilities and found that referral was not associated with other metrics, such as anemia management, morbidity, or mortality, and although referral was associated with waitlisting and transplantation, it was not entirely correspondent with these other measures of transplant access.…”

Should Transplant Referral Be a Clinical Performance Measure?

“…2 Agents targeting the IL-1 system (either IL-1 inhibitors or IL-1 receptor antagonists) have proven to be effective in some systemic inflammatory diseases, such as gout, rheumatoid arthritis, and adult-onset Still disease. Rilonacept is a soluble decoy receptor protein that acts by binding to IL-1a and Il-1b, thereby preventing activation of IL-1 receptors, 3 and has regulatory approval for treatment of a rare group of genetic inflammatory syndromes.…”

“…Most patients on dialysis are unable to complete the first three steps, which occur before transplant providers are involved. 2 In this issue of the Journal of the American Society of Nephrology, Patzer et al 3 show that interventions directed at dialysis facility practices can improve transplant referral, a task that reflects successful completion of the first three steps in the kidney transplant process. The authors randomly assigned 134 Georgia facilities to a control group that received usual care or an intervention group that received transplant education and engagement activities that targeted dialysis facility leadership, staff, and patients.…”

“…We also found that many patients who make an initial visit subsequently fail to fully complete the transplant center workup, which typically requires multiple visits over several months. 2 The findings by Patzer et al 3 raise the question of whether transplant referral should be a clinical performance measure for dialysis facilities. Good performance measures are those that address an important process or outcome, are positively influenced by practices undertaken by health care providers, and are based on transparent, minimally burdensome, and accurate data reporting.…”

What Else Can We Do to Ensure Transplant Equity for High-Risk Patients?

“…In the last 10 years, many patient, provider, system, and policy interventions to improve access to transplant have been recommended and tested (5)(6)(7). At a Consensus Conference on Best Practices in Live Kidney Donation, for example, 67 leaders aligned around recommendations to reduce racial disparities that included removing financial disincentives to transplant; implementing culturally tailored, community-based education at multiple stages of the transplant referral process; engaging a transplant liaison; and developing a research strategy to better understand transplant disparities (8).…”