Transplant Center Patient Navigator and Access to Transplantation among High-Risk Population

Abstract

Background and objectives Barriers exist in access to kidney transplantation, where minority and patients with low socioeconomic status are less likely to complete transplant evaluation. The purpose of this study was to examine the effectiveness of a transplant center-based patient navigator in helping patients at high risk of dropping out of the transplant evaluation process access the kidney transplant waiting list.Design, setting, participants & measurements We conducted a randomized, controlled trial of 401 patients (n=196 intervention and n=205 control) referred for kidney transplant evaluation (January 2013 to August 2014; followed through May 2016) at a single center. A trained navigator assisted intervention participants from referral to waitlisting decision to increase waitlisting (primary outcome) and decrease time from referral to waitlisting (secondary outcome). Time-dependent Cox proportional hazards models were used to determine differences in waitlisting between intervention and control patients.Results At study end, waitlisting was not significantly different among intervention (32%) versus control (26%) patients overall (P=0.17), and time from referral to waitlisting was 126 days longer for intervention patients. However, the effectiveness of the navigator varied from early (,500 days from referral) to late ($500 days) followup. Although no difference in waitlisting was observed among intervention (50%) versus control (50%) patients in the early period (hazard ratio, 1.03; 95% confidence interval, 0.69 to 1.53), intervention patients were 3.3 times more likely to be waitlisted after 500 days (75% versus 25%; hazard ratio, 3.31; 95% confidence interval, 1.20 to 9.12). There were no significant differences in intervention versus control patients who started evaluation (85% versus 79%; P=0.11) or completed evaluation (58% versus 51%; P=0.14); however, intervention patients had more living donor inquiries (18% versus 10%; P=0.03).Conclusions A transplant center-based navigator targeting disadvantaged patients improved waitlisting but not until after 500 days of follow-up. However, the absolute effect was relatively small.

Association of Socioeconomic Status and Comorbidities with Racial Disparities during Kidney Transplant Evaluation

“…Testing of mediation of SES, comorbidity, or SES and comorbidity on listing for kidney transplant within 1 year between black versus white patients with kidney failure (n53013) or receipt of transplant between black versus white kidney transplant candidates on the waitlist (n52068), using inverse odds ratio weighting and among a population who have started the transplant evaluation process disparities (4,(6)(7)(8)(9). It is at this point that transplant centers engage with candidates and have opportunities to influence the coordination of the transplant process (18,30). Our observed disparity in listing of 0.76 is consistent with studies among referred patients, where observed racial disparities ranged from 0.52 to 0.88 (10,11,13,16).…”

Impact of Navigators on First Visit to a Transplant Center, Waitlisting, and Kidney Transplantation

“…This is supported by a recent trial that found that involvement of a transplant center-based navigator did not significantly improve access to waitlisting among disadvantaged patients referred to a single transplant center. In that study, the navigator was a transplant social worker and made an average of about nine contacts with each patient (25). Moreover, the new waiting list allocation system, which counts time from start of dialysis rather than from listing, may make efficient workups less important (26).…”

Stepping Up to Reduce Racial Disparities in Transplantation

“…The foundation of any good living donor program is outreach, so Georgia recently tested the effectiveness of a program whereby trained kidney transplant recipients serve as patient navigators for patients with end‐stage kidney disease within dialysis facilities. This strategy increased patient referrals to a transplant center when combined with other educational interventions . The Emory Transplant Center has tested a social worker navigator intervention targeting mostly African‐Americans, and patients assigned a navigator experienced a higher number of living donor inquiries.…”