Increasing Equity in Transplant Evaluation and Living Donor Kidney Transplantation
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 入组人数
- 1,315
- 试验地点
- 2
- 主要终点
- Receipt of Kidney Transplant
研究概览
简要总结
Living donor kidney transplantation (LDKT) is the optimal treatment for end-stage kidney disease (ESKD). But, the evaluation process for a kidney transplant is lengthy, time consuming, and burdensome to the patient. Also, race disparities exist in rates of transplant evaluation completion, transplantation, and LDKT. Our previous and ongoing NIDDK-funded research indicates that cultural factors (i.e., perceived discrimination in health care, religious objection to LDKT), transplant knowledge, and demographic characteristics (e.g., age, education, income) independently and significantly predict time to complete transplant evaluation. In December 2012 the investigators' transplant center implemented a one-day streamlined evaluation process, dubbed Kidney Transplant Fast Track (KTFT), but it has not been evaluated for efficacy or cost effectiveness. Thus, the investigators propose a quasi-experiment to determine the efficacy and cost-effectiveness of the KTFT (n=1030) compared to historical controls (n=1140) who were recruited for the investigators' current NIDDK study to increase transplant rates. At the same time, the investigators will conduct a randomized controlled trial (RCT) targeting vulnerable patients with the educational component of the TALK intervention (Talking About Live Kidney Donation) to increase LDKT. For both components of the proposal, the investigators will target vulnerable populations because they are most at risk for extended evaluation times and lower rates of LDKT. Using CONSORT standards, participants will be randomly assigned to TALK (n=515) versus no-TALK (n=515) conditions and undergo two interviews at pre-transplant work-up and at completion of transplant evaluation in order to: (1) test whether KTFT and TALK will reduce transplant evaluation time, and increase rates of transplant and LDKT in members of vulnerable groups; (2) determine whether engaging in a streamlined and coordinated-care evaluation experience within the transplant center reduces negative perceptions of the healthcare system; and (3) test the cost effectiveness of the KTFT with TALK relative to standard practices. The results of this two-pronged approach will help pave the way for other transplant centers to implement a fast-track system at their sites, improve quality of care by transplanting a larger number of vulnerable patients, and may help address stark race/ethnic disparities in rates of LDKT.
详细描述
SPECIFIC AIMS Kidney transplantation (KT) is the optimal treatment for end-stage kidney disease (ESKD). It reduces mortality, improves quality of life, and is less costly than dialysis. Further, living donor KT (LDKT) is better than deceased donor KT (DDKT) because: (a) patients who can identify a living donor will get a KT much more quickly than ones awaiting DDKT and, (b) LDKT yields better outcomes than DDKT by improving cost effectiveness, reducing morbidity, and increasing long-term survival. The KT evaluation process, which occurs after patients have been referred for KT, is lengthy, time consuming, and burdensome to the patient. It requires patients to complete numerous tests (e.g., blood work, cardiac checks, pap smear, etc.) in order to be presented to the transplant team and accepted for KT. Although some variation between centers exists, typically patients must complete testing on their own, and ensure that their clinical providers forward results to the transplant team. This requires significant oversight and follow-up by the patient with each clinical provider.
The investigators' previous and ongoing NIDDK-funded research indicates that cultural factors (i.e., perceived discrimination in health care, religious objection to LDKT), KT knowledge, and demographic characteristics (e.g., age, education, income) independently and significantly predict time to complete KT evaluation. Similarly, the investigators' research found that African Americans (AA) take significantly longer to complete the evaluation process, and that the factors identified to predict longer time to complete evaluation are significantly associated with race. Other research has shown significant disparities in ESKD and its treatment for members of vulnerable groups (e.g., Hispanic/Latino, Native Americans, low income), and that African Americans (AA) are a particularly vulnerable group. For example, although ESKD in AA is four times greater than in whites (WH), AA are less than half as likely to undergo KT. AA race is associated with: (a) a longer time to complete evaluation for KT,19 (b) lower likelihood of getting a KT, (c) lower rates of pre-emptive listing for KT, and, (d) lower rates of LDKT versus DDKT. Therefore, two of the best ways to reduce disparities in KT may be to increase (a) the number of vulnerable group members who complete KT evaluation and (b) the rate of LDKT. This study is a two-pronged approach to address these two critical areas.
In December 2012 the investigators' transplant center implemented a one-day streamlined evaluation process, which they dubbed Kidney Transplant Fast Track (KTFT), but it has not been evaluated for efficacy or cost effectiveness. Thus, the investigators propose a quasi-experiment to determine the efficacy and cost-effectiveness in vulnerable groups of the KTFT compared to historical controls who were recruited for their previous NIDDK study. This component of the study will allow the investigators to take advantage of a unique and unusual natural experiment which occurred due to system-level clinical changes in the way patients are evaluated for KT at their center. The investigators will test if KTFT yields faster evaluation completion times, and ultimately higher KT rates. The second component of this study is to conduct a randomized controlled trial (RCT) targeting KTFT patients with the educational component of the TALK intervention to increase LDKT. The KT evaluation period poses an excellent opportunity to encourage patients to pursue LDKT. However, if the evaluation period is compressed via programs such as KTFT, it becomes critical to maximize patients' ability to pursue LDKT. For both the quasi-experimental and RCT components of this work, the investigators will target vulnerable populations because they are most at risk for extended evaluation times and lower rates of LDKT and these are the two most critical factors leading to disparities in KT. Specifically, the investigators intend to:
SA1: Test the efficacy and cost-effectiveness of a comprehensive, system-level fast-track KT evaluation for vulnerable groups in reducing time to complete KT evaluation, and increasing KT rates.
H1a: Compared to historical controls, evaluation time will be reduced with KTFT evaluation.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Health Services Research
- 盲法
- Single (Outcomes Assessor)
入排标准
- 年龄范围
- 18 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Patients who have scheduled a kidney transplant evaluation appointment at the Starzl Transplant Institute at the University of Pittsburgh Medical Center.
- •Male or female
- •English speaking
- •ESKD patients aged 18 and over
- •Patient has not previously received a kidney transplant
- •Patient has not been accepted for kidney transplant in another center
排除标准
- •Prior kidney transplant (excluded to eliminate the possibility that past experiences would affect their current treatment decisions)
- •Patient is already on the United Network for Organ Sharing (UNOS) waiting list through another center
- •Children under age 18 will be excluded because they have dissimilar underlying conditions, response patterns and decision-making authority as a result of their developmental stage and dependency on adult guardians.
结局指标
主要结局
Receipt of Kidney Transplant
时间窗: Assessed via Post- transplant medical record review. An average time period to receive transplant and assess this outcome is approximately 43.6 months from baseline.
This measure will assess whether or not the patient receives a kidney transplant
次要结局
- Time to complete transplant evaluation(Assessed via medical record at completion of KT evaluation (Time 2) which can take up to one year from baseline)
- Booklet and video helpfulness (assess perceptions of the quality and helpfulness of the video and booklet)(Assessed at completion of evaluation (Time 2) which can take place up to one year from baseline.)
- Type of transplant (whether the patient receives a Living or Deceased Donor Kidney Transplant)(Assessed via Post- transplant medical record review. An average time period to receive transplant and assess this outcome is approximately 43.6 months from baseline.)
- Kidney Transplant Decision Making (assessed using increasing levels of preference for a living versus deceased donor)(Assessed twice. First at initiation of pre-KT workup (Time 1) which is baseline. And next at the completion of evaluation (Time 2) which can take place up to one year from baseline.)
- Quality of Life (KDQOL-SF)(Assessed at completion of evaluation (Time 2) which can take place up to one year from baseline.)
研究者
Mary Amanda Dew
Mary Amanda Dew, PhD, Professor of Psychiatry, Psychology, Epidemiology, Biostatistics, and Clinical and Translational Science
University of Pittsburgh