The ASCENT Intervention to Improve Access and Reduce Racial Inequalities in Kidney Waitlisting

Abstract

Background The US kidney allocation system (KAS) changed in 2014, but dialysis facility staff (including nephrologists, social workers, nurse managers, and facility administrators) had low awareness of how this policy change could affect their patients' access to transplant. We assessed the effectiveness of a multicomponent and multilevel educational and outreach intervention targeting US dialysis facilities with low waitlisting, with a goal of increasing waitlisting and reducing Black versus White racial disparities in waitlisting. MethodsThe Allocation System Changes for Equity in Kidney Transplantation (ASCENT) study was a clusterrandomized, pragmatic, multilevel, effectiveness-implementation trial including 655 US dialysis facilities with low waitlisting, randomized to receive either the ASCENT intervention (a performance feedback report, a webinar, and staff and patient educational videos) or an educational brochure. Absolute and relative differences in coprimary outcomes (1-year waitlisting and racial differences in waitlisting) were reported among incident and prevalent patients.Results Among 56,332 prevalent patients, 1-year waitlisting decreased for patients in control facilities (2.72%-2.56%) and remained the same for patients in intervention facilities (2.68%-2.75%). However, the proportion of prevalent Black patients waitlisted in the ASCENT interventions increased from baseline to 1 year (2.52%-2.78%), whereas it remained the same for White patients in the ASCENT intervention facilities (2.66%-2.69%). Among incident patients in ASCENT facilities, 1-year waitlisting increased among Black patients (from 0.87% to 1.07%) but declined among White patients (from 1.54% to 1.27%). Significant racial disparities in waitlisting were observed at baseline, with incident Black patients in ASCENT facilities less likely to waitlist compared with White patients (adjusted odds ratio [aOR], 0.56; 95% confidence interval [CI], 0.35 to 0.92), but 1 year after the intervention, this racial disparity was attenuated (aOR, 0.84; 95% CI, 0.49 to 1.42). ConclusionsThe ASCENT intervention may have a small effect on extending the reach of the new KAS policy by attenuating racial disparities in waitlisting among a population of US dialysis facilities with low waitlisting.

Effect of a Novel Multicomponent Intervention to Improve Patient Access to Kidney Transplant and Living Kidney Donation

“…Trial findings may not be generalizable to other health care systems because dialysis practice patterns, patient case-mix, access to multidisciplinary care, and resources available to improve access to kidney transplant may vary across geographical regions . Finally, this intervention did not address inequities in access to transplantation, a key priority in health care …”

Implementation of the ASCENT Trial to Improve Transplant Waitlisting Access

“…Approximately 3 months after implementation of the ASCENT intervention (January–April 2017), intervention facilities were invited to participate in a web-based survey targeted at staff members primarily responsible for transplant education (e.g., nurse manager, social worker). The postimplementation survey assessed changes in knowledge and awareness of KAS changes, transplant education practices, and facility transplant referral and waitlisting practices from baseline (these results have been previously described), 24 , 25 and implementation questions. The postimplementation survey and interview guides were developed by the research team and the study’s Dissemination Advisory Board, which included dialysis facility medical directors; nephrologists; social workers; patients with ESRD; ESRD Network 6 staff; and regional members of the Southeastern Kidney Transplant Coalition, an academic-community partnership in Georgia, North Carolina, and South Carolina, committed to eliminating health disparities in kidney transplant.…”

“…Implementation outcomes were examined among incident and prevalent dialysis patients (study population details are described elsewhere), 24 Dialysis Facility Report data were used to obtain facility-level and United States Renal Data System data were used to obtain patient-level baseline (January–December 2016) and postimplementation (April 2017–March 2018) characteristics and outcomes within ASCENT facilities. Coprimary outcomes of effectiveness were 1-year postintervention changes in the following: (i) mean percentage of patients waitlisted per facility, and (ii) mean percentage of patients waitlisted per facility, stratified by race.…”

“… 23 Effectiveness results found that the intervention had a small effect on extending the reach of the new KAS policy by attenuating racial disparities in waitlisting among a population of US dialysis facilities with low waitlisting and increasing provider knowledge of transplant policy. 24 , 25 However, no study has examined the contextual factors related to the implementation of ASCENT, which can aid in the interpretation of effectiveness results and scaling of the intervention more broadly. 26 Therefore, the secondary aim of the ASCENT study was to assess implementation of the ASCENT intervention through a process evaluation.…”

The Vexing Problem of Persistent Disparities in Kidney Transplant Care

“…In this issue of CJASN , Patzer, et al 8 present findings from The Allocation System Changes for Equity in Kidney Transplantation (ASCENT), a cluster-randomized pragmatic effectiveness-implementation trial designed to increase kidney transplant waitlisting and reduce racial disparities in waitlisting across US dialysis facilities. ASCENT investigators randomized 655 US dialysis facilities in the lowest tertile of kidney transplantation waitlisting rates to receive a multilevel, multimodal educational intervention including performance feedback reporting versus control and subsequently assessed a primary outcome of changes in facility waitlisting percentages and racial differences in waitlisting at 1 year postintervention, for both incident and prevalent patients with kidney failure.…”