Reducing Disparities in Access to Kidney Transplantation

我们之前确定了移植过程中造成种族和性别差异的移植过程中的步骤。我们认为，训练有素的肾移植受者可能是帮助其他患者完成这些步骤的理想导航员。在最近完成的一项疗效试验中，我们证明了随机分配到导航器的透析患者完成的步骤是对照组患者的三倍。此外，黑人、白人、男性和女性对这一干预的反应都相似，这表明导航可能有助于缩小差距。然而，导航干预是劳动密集型的，专注于单一的地理区域，并不是为了确定在等待名单放置或实际移植方面具有统计学意义的影响。 将成功的临床试验干预措施推广到广泛的实践中仍然是一个长期存在的问题。我们使用了一种理论驱动的方法来解决传播我们干预的障碍。特别是，我们简化了干预，减少了数据收集需求，并与多个移植中心合作。我们现在建议在一项为期四年的多点整群随机试验中传播和评估简化的导航仪干预，该试验涉及4个移植中心、40个附近的透析机构和1800名透析患者。每个移植中心的导航员将在干预设施而不是在控制设施为患者提供量身定制的信息和帮助。初步分析将比较干预组和控制组的等待登记和移植比率。 帮助患者完成移植过程中的步骤不仅可以减少移植过程中的差异，还可以改善患者的存活率，提高生活质量，并降低医疗保健成本。拟议的项目也可以作为传播其他健康差距干预措施的模式。

We previously identified the steps in the transplant process that are responsible for creating race and gender disparities in access to kidney transplantation. We reasoned that trained kidney transplant recipients may be ideal navigators to help other patients complete these steps. In a recently completed efficacy trial, we demonstrated that dialysis patients randomly assigned to navigators completed three times more steps compared to control patients. Moreover, blacks, whites, men, and women all responded similarly to the intervention, suggesting that navigation may help reduce disparities. However, the navigation intervention was labor intensive, focused on a single geographic area, and was not designed to determine a statistically significant effect on waiting list placement or actual transplantation. Dissemination of successful clinical trial interventions into widespread practice remains a persistent problem. We used a theory-driven approach to address impediments to dissemination of our intervention. In particular, we simplified the intervention, reduced data collection needs, and partnered with multiple transplant centers. We now propose to disseminate and evaluate a streamlined navigator intervention in a four-year, multi-site, cluster randomized trial involving 4 transplant centers, 40 nearby dialysis facilities, and 1800 dialysis patients. A navigator based at each transplant center will provide tailored information and assistance to patients at intervention but not at control facilities. Primary analyses will compare wait listing and transplant rates in the intervention and control groups. Helping patients complete steps in the transplant process may lead not only to reduced disparities in transplantation but also to better patient survival, improved quality of life, and decreased health care costs. The proposed project may also serve as a model for dissemination of other health disparity interventions.