The RaDIANT Health Systems Intervention for Equity in Kidney Transplantation

摘要 对于大多数终末期肾功能衰竭患者，肾移植可以延长生存期，改善治疗质量， 寿命和较低的成本。尽管有这些好处，但很少有患者能够通过复杂的 移植评估过程，以及长期存在的种族和社会经济不平等存在于获得每一个 移植步骤，包括转诊、开始和完成移植评估，以及在 等候名单在2010年，随着明确的目标，以改善公平获得移植在美国东南部 包括格鲁吉亚、北卡罗来纳州和南卡罗来纳州在内的地区，我们创建了东南肾 移植联盟，一个由移植利益相关者组成的社区，包括患者，护理人员，医疗人员， 专业人士，患者倡导团体和卫生系统管理员，包括所有10个移植 这些州的中心和大型透析组织为超过50，000名肾病患者提供服务 失败自成立以来，我们的联盟进行了几次教育和 在透析机构、提供者和患者层面开展质量改进活动，发现 转诊和评估开始，并减少黑人与白色患者之间这些结局的种族差异 以及社会经济地位较低和较高的人。不幸的是，卫生系统的障碍持续存在， 转诊和教育：超过一半的转诊患者没有开始移植评估，65%的 被推荐的人从未被列入候补名单。然而，先前的干预措施仅限于对患者的干预- 和透析设施的水平，并没有解决整个健康的复杂过程中的结构性障碍， 患者必须导航以获得移植的系统，包括透析设施和移植中心。 在对卫生系统工作人员的调查和范围审查中，我们发现了持续存在的卫生系统障碍， 移植公平性，包括安排后勤，整个卫生系统的提供者沟通不足， 以及移植提供者对不平等的认识有限。在这个拟议的Radiant健康系统中， 干预，我们将利用我们的研究证明的干预措施，并使用以社区为基础的参与式 研究方法，以适应和加强针对结构性的RaDIANT干预措施的可持续性 评估的障碍始于卫生系统一级（目标1）。然后我们将进行混合1型 在4名受试者中进行的RaDIANT卫生系统干预措施的有效性-实施准实验研究 东南部移植中心和佐治亚州、北卡罗来纳州和南卡罗来纳州的约800家透析机构，目标是减少种族歧视。 和社会经济不平等的移植访问（目标2）。最后，我们将进行过程评估 在参与的卫生系统中评估可接受性、可用性、实施和可持续性， （目标3）。如果成功，干预措施可以在全国范围内调整和推广， 系统合作伙伴致力于公平获得肾移植。

Abstract For most patients with end-stage kidney failure, kidney transplantation confers longer survival, better quality of life, and lower cost, relative to dialysis. Despite these benefits, too few patients make it through the complex transplant evaluation process, and long-standing racial and socioeconomic inequities exist in access to each transplant step, including referral, start and completion of the transplant evaluation, and placement on the waiting list. In 2010, with the explicit goal of improving equity in access to transplant in the US Southeastern region that includes Georgia, North Carolina, and South Carolina, we created the Southeastern Kidney Transplant Coalition, a community of transplant stakeholders, including patients, caregivers, medical professionals, patient advocacy groups, and health system administrators that encompasses all 10 transplant centers in these states and large dialysis organizations serving a population of >50,000 patients with kidney failure. Since its inception, our Coalition has conducted several pragmatic interventions of educational and quality improvement activities at the dialysis facility, provider, and patient levels, finding increased rates of referral and evaluation start, and reduced racial disparities in these outcomes among Black vs. White patients and those with lower vs. higher socioeconomic status. Unfortunately, health system barriers persist after referral and education: more than half of patients referred did not start the transplant evaluation, and 65% of those referred were never waitlisted. However, prior interventions were limited to interventions at the patient- and dialysis facility-levels and did not address the structural barriers in the complex process across the health systems that patients must navigate to get a transplant, including both dialysis facilities and transplant centers. In surveys of health system staff and a scoping review, we identified persistent health system barriers to transplant equity, including scheduling logistics, inadequate provider communication across health systems, and limited transplant provider awareness of inequities. In this proposed RaDIANT Health Systems intervention, we will leverage proven interventions from our research and use a community-based participatory research approach to adapt and enhance sustainability of the RaDIANT interventions targeting structural barriers to evaluation start at the health system level (Aim 1). We will then conduct a hybrid type 1 effectiveness-implementation quasi-experimental study of the RaDIANT Health System intervention among 4 Southeastern transplant centers and ~800 dialysis facilities in GA, NC, and SC with a goal of reducing racial and socioeconomic inequities in transplant access (Aim 2). Finally, we will conduct a process evaluation among the participating health systems to assess acceptability, usability, implementation, and sustainability of interventions (Aim 3). If successful, interventions could be adapted and scaled nationally, where our health system partners are committed to equity in access to kidney transplantation.