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Author(s): McSorley, AMM; Peipert, JD; Gonzalez, C; Norris, KC; Goalby, CJ; Peace, LJ; Waterman, AD | Abstract: Although mandates require all dialysis patients be informed about transplant, Black and low-income patients remain less likely to receive transplant education, and significant racial and socioeconomic disparities in access to transplant persist. This mixed methods study, utilizing surveys and focus groups, examined 48 dialysis providers’ perceptions of transplant barriers for Black and low-income patients. Focus group transcripts were coded for common themes, which were organized by level of the Socio-Ecological Model for Transplant (SEMT). On surveys, over 50 percent of providers reported having insufficient time to provide transplant education. In focus groups, providers perceived that Black and low-income patients experience greater barriers to transplant. These perceptions, as well as limited time and resources, could enable subtle biases against comprehensive transplant education for these patient groups to emerge. Raising awareness among providers about existing biases and supplementing transplant education within dialysis centers may improve the consistency of education and access to transplant.

Author(s): Waterman, Amy D; Peipert, John D; Xiao, Huiling; Goalby, Christina J; Kawakita, Satoru; Cui, Yujie; Lentine, Krista L | Abstract: BackgroundTransplant education in dialysis centers can increase access to kidney transplant; however, dialysis center transplant barriers are common, and limited research identifies the most effective transplant education approaches.MethodsWe surveyed transplant educators in 1694 US dialysis centers about their transplant knowledge, use of 12 education practices, and 8 identified education barriers. Transplant wait-listing rates were calculated using US Renal Data System data.ResultsFifty-two percent of educators orally recommended transplant to patients, 31% had in-center transplant discussions with patients, 17% distributed print educational resources, and 3% used intensive education approaches. Distribution of print education (incident rate ratio: 1.021.151.30) and using g1 intensive education practice (1.001.111.23) within dialysis centers were associated with increased wait-listing rates. Several dialysis center characteristics were associated with reduced odds of using education strategies leading to increased wait-listing. Centers with greater percentages of uninsured patients (odds ratio [OR]: 0.960.970.99), in rural locations (OR: 0.660.790.95), with for-profit ownership (OR: 0.640.770.91), and with more patients older than 65 years (OR: 0.050.110.23) had lower odds of recommending transplant, while centers with a higher patient-to-staff ratio were more likely to do so (OR: 1.011.031.04). Language barriers (OR: 0.480.640.86) and having competing work priorities (OR: 0.400.530.70) reduced the odds of distributing print education. Providers with greater transplant knowledge were more likely to use g1 intensive educational strategy (OR: 1.011.271.60) while providers who reported competing work priorities (OR: 0.510.660.84) and poor communication with transplant centers (OR: 0.580.760.98) were less likely to do so.ConclusionsEducators should prioritize transplant education strategies shown to be associated with increasing wait-listing rates.

Rationale & Objective Compared with others, black and low-income patients receiving dialysis are less likely to receive kidney transplantation (KT) education within dialysis centers. We examined the efficacy of 2 supplementary KT education approaches delivered directly to patients. Study Design Prospective, 3-arm parallel-group, randomized, controlled trial. Settings & Participants Adult, black, and white low-income patients receiving dialysis in Missouri. Intervention Patients were randomly assigned to 1 of 3 educational conditions: (1) standard of care, usual KT education provided in dialysis centers (control); (2) Explore Transplant @ Home patient-guided, 4 modules of KT education sent directly to patients using print, video, and text messages; and (3) Explore Transplant @ Home educator-guided, the patient-guided intervention plus 4 telephonic discussions with an educator. Outcomes Primary: patient knowledge of living (LDKT) and deceased donor KT (DDKT). Secondary: informed decision making, change in attitudes in favor of LDKT and DDKT, and change in the number of new steps taken toward KT. Results In intent-to-treat analyses, patients randomly assigned to educator- and patient-guided interventions had greater knowledge gains (1.4 point increase) than control patients (0.8 point increase; P=0.02 and P=0.01, respectively). Compared with control patients, more patients randomly assigned to educator- and patient-guided interventions were able to make informed decisions about starting KT evaluation (82% vs 91% and 95%; P=0.003), pursuing DDKT (70% vs 84% and 84%; P=0.003), and pursuing LDKT (73% vs 91% and 92%; P Limitations Potential contamination because of patient-level randomization; no assessment of clinical end points. Conclusions Education presented directly to dialysis patients, with or without coaching by telephone, increased dialysis patients' KT knowledge and informed decision making without increasing educational burden on providers. Funding Source This project was funded by the National Institutes of Health and Health Resources and Services Administration. Trial Registration Registered at ClinicalTrials.gov with study number NCT02268682.

© 2015 by the American Society of Nephrology. Background and objectives The Centers for Medicare & Medicaid Services (CMS) requires that dialysis centers informnewpatients of their transplant options and document compliance using theCMS-2728Medical Evidence Form (Form-2728). This study compared reports of transplant education for new dialysis patients reported to CMS with descriptions from transplant educators (predominantly dialysis nurses and social workers) of their centers’ quantity of and specific educational practices. The goal was to determine what specific transplant education occurred and whether provision of transplant education was associated with center-level variation in transplant wait-listing rates. Design, setting, participants, & measurements Form-2728 data were drawn for 1558 incident dialysis patients at 170 centers in theHeartland Kidney Network (Iowa, Kansas,Missouri, and Nebraska) in 2009–2011; educators at these centers completed a survey describing their transplant educational practices. Educators’ own survey responses were compared with Form-2728 reports for patients at each corresponding center. The association of quantity of transplant education practices used with wait-listing rates across dialysis centerswas examined using multivariable negative binomial regression. Results According to Form-2728, 77% of patients (n=1203) were informed of their transplant options within 45 days. Educators, who reported low levels of transplant knowledge themselves (six of 12 questions answered correctly), most commonly reported giving oral recommendations to begin transplant evaluation (988 informed patients educated, 81%of centers) and referrals to external transplant education programs (959 informed patients educated, 81% of centers). Only 18% reported having detailed discussions about transplant with their patients. Compared with others, centers that used more than three educational activities (incident rate ratio, 1.36; 95% confidence interval, 1.07 to 1.73) had higher transplant wait-listing rates. ConclusionsWhile most educators inform new patients that transplant is an option, dialysis centers with higher wait-listing rates use multiple transplant education strategies.

Because of the deceased donor organ shortage, more kidney patients are considering whether to receive kidneys from family and friends, a process called living donor kidney transplantation (LDKT). Although Blacks and Hispanics are 3.4 and 1.5 times more likely, respectively, to develop end stage renal disease (ESRD) than Whites, they are less likely to receive LDKTs. To address this disparity, a new randomized controlled trial (RCT) will assess whether Black, Hispanic, and White transplant patients’ knowledge, readiness to pursue LDKT, and receipt of LDKTs can be increased when they participate in the Your Path to Transplant (YPT) computer-tailored intervention. Nine hundred Black, Hispanic, and White ESRD patients presenting for transplant evaluation at University of California, Los Angeles Kidney and Pancreas Transplant Program (UCLA-KPTP) will be randomly assigned to one of two education conditions, YPT or Usual Care Control Education (UC). As they undergo transplant evaluation, patients in the YPT condition will receive individually-tailored telephonic coaching sessions, feedback reports, video and print transplant education resources, and assistance with reducing any known socioeconomic barriers to LDKT. Patients receiving UC will only receive transplant education provided by UCLA-KPTP. Changes in transplant knowledge, readiness, pros and cons, and self-efficacy to pursue LDKT will be assessed prior to presenting at the transplant center (baseline), during transplant evaluation, and 4- and 8-months post-baseline, while completion of transplant evaluation and receipt of LDKTs will be assessed at 18-months post-baseline. The RCT will determine, compared to UC, whether Black, Hispanic, and White patients receiving YPT increase in their readiness to pursue LDKT and transplant knowledge, and become more likely to complete transplant medical evaluation and pursue LDKT. It will also examine how known patient, family, and healthcare system barriers to LDKT act alone and in combination with YPT to affect patients’ transplant decision-making and behavior. Statistical analyses will be performed under an intent-to-treat approach. At the conclusion of the study, we will have assessed the effectiveness of an innovative and cost-effective YPT intervention that could be utilized to tailor LDKT discussion and education based on the needs of individual patients of different races in many healthcare settings. ClinicalTrials.gov, number NCT02181114 .

When senior leadership endorses quality improvement priorities, their staff is more likely to comply. To honor Centers for Medicare and Medicaid Services’s (CMS) mandates, dialysis clinic managers must ensure that transplant education takes place within their centers. We surveyed 131 dialysis clinic managers in End Stage Renal Disease (ESRD) Network 12 (the Heartland Kidney Network) to understand their transplant attitudes, knowledge, active educational programs, and perceived barriers to transplant. Few reported that there was a designated transplant educator (40%) or formal transplant education program (33%) available at their dialysis centers. Transplant education most commonly occurring with all patients included educators (53%) or physicians (49%) discussing transplant with the patient, giving them handouts or brochures (40%), the transplant center phone numbers (36%), and referring them to other transplant educational resources (22%). Over half were dissatisfied with transplant education available (56%) and felt that their educators did not have sufficient time to educate (57%). Most did not know that a kidney transplant from a living donor is expected to last 15-20 years (78% incorrect) or that almost 90% of kidneys function for at least one year (71% incorrect). Managers with formal transplant education programs in their dialysis centers were more likely to report that their patients were talking to educators (80% vs. 49%, χ2=11.13, p

© 2015 Waterman et al. Background: Compared to others, dialysis patients who are socioeconomically disadvantaged or Black are less likely to receive education about deceased donor kidney transplant (DDKT) and living donor kidney transplant (LDKT) before they reach transplant centers, often due to limited availability of transplant education within dialysis centers. Since these patients are often less knowledgeable or ready to pursue transplant, educational content must be simplified, made culturally sensitive, and presented gradually across multiple sessions to increase learning and honor where they are in their decision-making about transplant. The Explore Transplant at Home (ETH) program was developed to help patients learn more about DDKT and LDKT at home, with and without telephone conversations with an educator. Methods and Study Design: In this randomized controlled trial (RCT), 540 low-income Black and White dialysis patients with household incomes at or below 250 % of the federal poverty line, some of whom receive financial assistance from the Missouri Kidney Program, will be randomly assigned to one of three education conditions: (1) standard-of-care transplant education provided by the dialysis center, (2) patient-guided ETH (ETH-PG), and (3) health educator-guided ETH (ETH-EG). Patients in the standard-of-care condition will only receive education provided in their dialysis centers. Those in the two ETH conditions will receive four video and print modules delivered over an 8 month period by mail, with the option of receiving supplementary text messages weekly. In addition, patients in the ETH-EG condition will participate in multiple telephonic educational sessions with a health educator. Changes in transplant knowledge, decisional balance, self-efficacy, and informed decision making will be captured with surveys administered before and after the ETH education. Discussion: At the conclusion of this RCT, we will have determined whether an education program administered to socioeconomically disadvantaged dialysis patients, over several months directly in their homes, can help more individuals learn about the options of DDKT and LDKT. We also will be able to examine the efficacy of different educational delivery approaches to further understand whether the addition of a telephone educator is necessary for increasing transplant knowledge. Trial Registration: ClinicalTrials.gov, NCT02268682.