The RaDIANT Health Systems Intervention for Improving Access to Kidney Transplantation - 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. Some patients, including individuals residing in certain geographic regions and those with lower socioeconomic status, experience substantially lower 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 access to transplant in the US Southeastern region that includes Georgia, North Carolina, and South Carolina, we created the Southeastern Kidney Transplant Coalition, a collaborative of transplant community members, including patients, caregivers, medical professionals, patient advocacy groups, and health system administrators that encompasses all 11 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. 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. Prior interventions were limited to interventions at the patient- and dialysis facility-levels and did not address the structural barriers embedded in dialysis and transplant center policies and practices, which impede patient progression in the complex process to get a transplant. In surveys of health system staff and a scoping review, we identified persistent health system barriers to transplant access, including referral closure policies, fundraising requirements, scheduling logistics, and inadequate communication among providers across health systems. Leveraging proven interventions from our research and using a community-based participatory research approach, we will adapt and enhance the sustainability of the RaDIANT interventions targeting structural barriers to evaluation start at the health system level (Aim 1). The developed RaDIANT Health Systems intervention, which includes transplant center audit-and-feedback or “benchmarking” reports related to referral and evaluation, and facility-specific quality improvement activities focused on enhancing communication, streamlining referral follow-up, and improving patient engagement through more coordinated practices between dialysis and transplant centers, will be evaluated through a hybrid type 1 effectiveness-implementation quasi-experimental study among 4 Southeastern transplant centers and ~800 dialysis facilities in GA, NC, and SC with a goal of improving transplant access (Aim 2). Finally, we will conduct a process evaluation among the participating health systems to assess the 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 improving access to kidney transplantation for individuals whose access has been obstructed by health system-level barriers.
