Multi-level Factors that Influence Dialysis Facilities' Assessments of Patient Suitability for Transplantation

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Project Summary/Abstract For most patients with end-stage renal disease (ESRD), kidney transplantation is the optimal treatment. Underserved racial/ethnic minority and low-income individuals have a greater burden of ESRD (higher incidence and more rapid progression), yet they have much poorer access to transplant. Before patients are considered for waitlisting at a transplant center, dialysis facility teams perform complex medical and psychosocial assessments of patients' suitability for transplant and decide whether to refer them to a transplant center for full evaluation. These pre-referral assessment processes, which vary widely across clinical teams, have been identified as among the most important potential drivers of downstream disparities in transplant waitlisting and receipt. The objective of this application for a NIDDK Mentored Research Scientist Development Award (K01) is to support an assistant professor at the Emory University Rollins School of Public Health to become an independent health services researcher fully equipped with the skills to build understanding of these patient assessment processes and to improve their treatment outcomes. To that end, this K01 award will provide training in clinical nephrology, qualitative and survey research methods, implementation science frameworks, and grant-writing. The research aims are designed to reinforce and apply these new skills and concepts in an investigation of dialysis facilities' pre-referral patient assessment processes. Specifically, the K01's research objective is to use rigorous qualitative and survey research methods to elucidate the measurable and modifiable provider-level constructs of cognitive load (stress, time pressure, disruptions) and uncertainty tolerance (anxiety or worry in response to uncertainty) and their impact on disparities in pre-referral assessments within their dialysis facility context. Aim 1 will use qualitative methods to explore how provider- level factors (e.g., cognitive load, uncertainty tolerance) and multi-level contextual factors (e.g., facility-level standard protocols, local transplant center policies) shape dialysis facility teams' processes for pre-referral patient assessment. Aim 2 will develop and validate a survey to quantify staff, dialysis facility, and community characteristics in the context of pre-referral assessments using a survey pilot and a rigorous modified Delphi approach. Aim 3 will conduct a survey of n≈2000 dialysis facility staff across 13 states and use linked data on patient transplant evaluation outcomes (referral, evaluation start, and waitlisting) to assess how staff cognitive load and uncertainty tolerance are related to racial/ethnic and socioeconomic disparities in transplant access as well as dialysis facility and community characteristics. The protected time, resources, and mentoring available through this career development award will enable Dr. Adam Wilk to emerge as an independent and leading researcher, conducting groundbreaking survey research and fostering the development and implementation of multi-level interventions to address barriers in access to transplant or other preferred treatments for underserved patients with kidney disease and other complex chronic conditions.