Improving Quality and Access to Early Steps in Kidney Transplantation

摘要 肾移植提供更长的生存期，更好的生活质量，减少住院治疗，降低费用 相对于美国> 500，000名接受透析的终末期肾病（ESRD）患者的透析。尽管 根据这一证据，只有18.5%的终末期肾病患者等待肾移植。广泛的人口 研究发现，美国ESRD患者的肾移植可及性存在很大差异， 透析设施和移植中心，由于病人，邻里和卫生系统层面的因素，但没有 存在关于早期肾移植步骤的国家监测数据。我们首要的长期目标是消除 在高度复杂的肾脏的每一个步骤中， 移植过程。我们的具体目标是：（1）描述透析设施和移植中心的差异， 肾移植过程的早期步骤，包括a）转诊进行肾移植评估，B）开始 移植评估过程，以及c）在国家已故捐赠者等待名单上的位置，以及（2） 确定患者，社区和健康中心水平的障碍，解释这些早期的差异 参与ESRD网络的美国东南部、美国东北部和 俄亥俄州河谷，并确定障碍在不同地理区域的变化。 本研究将在东南部（GA， 北卡罗来纳州、南卡罗来纳州）、东北部（CT、MA、ME、NH、NY、RI、VT）和俄亥俄州河谷（IN、KY、OH）， 移植中心，约1，800家透析机构和约155，000例ESRD患者。有了这些新数据，我们 将进行关键的流行病学分析，以描述几种结果的区域差异，包括： 透析机构级肾移植转诊率，B）透析机构级评价开始率，以及c） 移植中心的等待率在那些谁发起的评估过程。在目标2中，我们将确定 使用多级模型以及透析设施的这些重要移植步骤的障碍， 移植中心提供者调查和患者焦点小组。这项工作将有助于确定地理 肾移植转诊率和评估率最低的地区和透析设施， 了解移植获得率最低的人群的特征。数据的日期及时间为 分发给每个地理区域的ESRD网络领导人， 中心和其他利益相关者，在那里他们可以针对区域质量改进工作，以改善获得 并减少肾移植的差异。结果还将为未来的多层次和多成分 根据每个地理区域的需要调整干预措施。

Abstract Kidney transplantation offers longer survival, better quality of life, reduced hospitalization, and lower cost relative to dialysis for the >500,000 end-stage renal disease (ESRD) patients on dialysis in the US. Despite this evidence, only 18.5% of ESRD patients are waitlisted for a kidney transplant. Extensive population research has identified substantial variability in kidney transplant access among US ESRD patients as well as dialysis facilities and transplant centers due to patient-, neighborhood- and health system-level factors, but no national surveillance data exist on early kidney transplant steps. Our overarching, long-term goal is to eliminate inequities and improve healthcare delivery for ESRD patients in every step of the highly complex kidney transplant process. Our specific aims are to: (1) describe dialysis facility and transplant center differences in early steps of the kidney transplantation process, including a) referral for kidney transplant evaluation, b) start of the transplant evaluation process, and c) placement on the national deceased donor waiting list and (2) determine the patient-, neighborhood-, and health center-level barriers that explain disparities in these early steps of kidney transplantation among participating ESRD Networks in the Southeast US, Northeast US, and Ohio River Valley, and determine how barriers vary across geographic region. This study will be conducted in a geographically diverse population of ESRD patients in the Southeast (GA, NC, SC), Northeast (CT, MA, ME, NH, NY, RI, VT) and the Ohio River Valley (IN, KY, OH) representing 48 transplant centers, ~1,800 dialysis facilities, and ~155,000 incident ESRD patients. With these novel data, we will conduct critical epidemiologic analyses to describe regional variability in several outcomes, including: a) dialysis facility-level kidney transplant referral rates, b) dialysis facility-level evaluation start rates, and c) transplant center waitlisting rates among those who initiated the evaluation process. In Aim 2, we will identify the barriers to these important transplant steps using multilevel models as well as dialysis facility and transplant center provider surveys and patient focus groups. This work will help to identify the geographic regions and the dialysis facilities with the lowest rates of kidney transplant referral and evaluation and better understand the characteristics of the populations with lowest rates of transplantation access. Findings will be disseminated to the respective ESRD Network leaders in each geographic region as well as to transplant centers and other stakeholders, where they can target regional quality improvement efforts to improve access and reduce disparities in kidney transplantation. Results will also inform future multi-level and multicomponent interventions adapted to fit the needs of each geographic region.