Study shows disparities in access to kidney transplants can be reduced through multilevel quality improvement efforts

An academic medical center in Charleston, South Carolina, was able to significantly improve access to kidney transplants for African Americans by streamlining and standardizing the assessment process, improving patient education. individuals and staff, and expanding the use of virtual visits and organs from high-risk donors, according to the study published as a “press article” in Journal of the American College of Surgeons.

Over the years, research has noted that African-Americans have reduced access to kidney transplants and are significantly underrepresented on the kidney. transplant waiting list.

Lead author Derek A. DuBay, MD, MSPH, said: “Interventions to reduce structural barriers to transplant access significantly increase the proportion of African Americans who are able to complete the assessment. transplant, added to the transplant waiting list, and finally transplanted.” a transplant surgeon at the Medical University of South Carolina (MUSC) in Charleston.

Dr. DuBay said fewer referrals of African-Americans for kidney transplant evaluations have long been thought to be a major cause of inequality problems. However, recent transplant data suggest that African Americans are more likely white patient referred for renal transplantation evaluation. This surprising finding may be because African-Americans tend to go in CKD Dr. DuBay said they are able to have dialysis earlier and can be on dialysis longer than the general population, so they have a better chance of being referred.

Dr DuBay said: “The real problem is that the transplant centers didn’t put them on the assessment to put them on the waiting list. “We pointed the finger elsewhere when it should have been pointed at us.”

Reduce barriers to evaluation

in one retrospective study After five years of data on patients with end-stage renal disease at MUSC, Dr. DuBay’s team measured the impact of quality-improvement interventions that reduce key barriers to assessment. price once the patient is referred for a transplant. These interventions were developed at MUSC with the aim of reducing barriers without compromising the key medical and psychosocial assessments required for evaluation.

One intervention introduced more uniform protocols to reduce variability in medical and social assessment among providers. A team of transplant nephrologists, transplant surgeons, cardiologists, and social workers streamlined and standardized the assessment process. Dr DuBay said any lab or test that could be eliminated reduced one hurdle for patients. For example, former smokers are often asked to have chest imaging, although research does not show that former smokers who receive a kidney transplant are more likely to die of respiratory failure during the surgery.

In addition, virtual visits were used for the initial assessment as well as several subsequent social work, dietary, and pharmaceutical assessments. As a result, the critical medical test-focused in-person assessment can be completed in one day instead of taking up to three days.

The center also uses organs from higher-risk donors, including those with hepatitis C infection, acute kidney injury, or those who have died of heart disease. Outcomes were monitored to ensure that higher donor use did not adversely affect results.

Finally, an education program for dialysis center staff and patients addressed misconceptions and misunderstandings about the kidney transplant procedure. A previous study has shown that this intervention increased patient knowledge.

Main research results

Reviewing patient data from January 2017 to September 2021, the researchers analyzed 11,487 referrals of end-stage renal disease (64.7% African-American) patients, including 6,748 who initiated the assessment (62.8% African-American), 4,109 who completed the assessment (59.7% African-American), 2,762 people placed on the waiting list (60.0% American-American). Africa) and 1,229 people have experienced kidney transplant (55.3% African-American). They found that these interventions:

• Significantly reduce inequality among African-Americans with regard to assessment initiation, completion, and waitlist addition.
• Increase access to implants without compromising results.

The study also found that the interventions reduced inequalities in transplants and increased transplant survival, but none of the results were found to be statistically significant.

“I am proud of the results of organ transplant survival, especially given the fact that our organ acceptance rate is nearly 2.5 times the national average,” said Dr. DuBay. He also noted that last year his center had the second most number of waitlisted additions in the US.

Although the study was not designed to show which interventions are most effective, Dr DuBay says virtual visits may have the greatest impact in reducing barriers to clinical assessment. ways to reduce the need for time and expense for patients and caregivers to travel to the hospital. visit the office, he said.

Dr. DuBay would like to see further studies to determine if the results are durable, which specific interventions provide the greatest impact, and whether these results can be replicated in transplant centers. other grafts or not.

Study co-authors are David J Taber, PharmD, MS; Trach Su, MS; Dr. Mulugeta Gebregziabher; Patrick D. Mauldin, PhD; Dr. Thomas A. Morinelli; Ammar O. Mahmood, MD; Dr. Gayenell S. Magwood; Michael J. Casey, MD; Joseph R. Scalea, MD; Sam M. Kavarana, BS; Prabhakar K. Baliga, MD, FACS; and James R. Rodrigue, Ph.D.