Direct Delivery of Kidney Transplant Education to Black and Low-Income Patients Receiving Dialysis: A Randomized Controlled Trial

Amy D Waterman, John Devin Peipert, Anna-Michelle McSorley, Christina J Goalby, Jennifer L Beaumont, Leanne Peace, Amy D Waterman, John Devin Peipert, Anna-Michelle McSorley, Christina J Goalby, Jennifer L Beaumont, Leanne Peace

Abstract

Rationale & objective: Compared with others, black and low-income patients receiving dialysis are less likely to receive kidney transplantation (KT) education within dialysis centers. We examined the efficacy of 2 supplementary KT education approaches delivered directly to patients.

Study design: Prospective, 3-arm parallel-group, randomized, controlled trial.

Settings & participants: Adult, black, and white low-income patients receiving dialysis in Missouri.

Intervention: Patients were randomly assigned to 1 of 3 educational conditions: (1) standard of care, usual KT education provided in dialysis centers (control); (2) Explore Transplant @ Home patient-guided, 4 modules of KT education sent directly to patients using print, video, and text messages; and (3) Explore Transplant @ Home educator-guided, the patient-guided intervention plus 4 telephonic discussions with an educator.

Outcomes: Primary: patient knowledge of living (LDKT) and deceased donor KT (DDKT). Secondary: informed decision making, change in attitudes in favor of LDKT and DDKT, and change in the number of new steps taken toward KT.

Results: In intent-to-treat analyses, patients randomly assigned to educator- and patient-guided interventions had greater knowledge gains (1.4 point increase) than control patients (0.8 point increase; P=0.02 and P=0.01, respectively). Compared with control patients, more patients randomly assigned to educator- and patient-guided interventions were able to make informed decisions about starting KT evaluation (82% vs 91% and 95%; P=0.003), pursuing DDKT (70% vs 84% and 84%; P=0.003), and pursuing LDKT (73% vs 91% and 92%; P<0.001).

Limitations: Potential contamination because of patient-level randomization; no assessment of clinical end points.

Conclusions: Education presented directly to dialysis patients, with or without coaching by telephone, increased dialysis patients' KT knowledge and informed decision making without increasing educational burden on providers.

Funding source: This project was funded by the National Institutes of Health and Health Resources and Services Administration.

Trial registration: Registered at ClinicalTrials.gov with study number NCT02268682.

Keywords: Kidney transplantation; dialysis; end-stage renal disease (ESRD); low income; patient education; poverty; racial disparities; randomized controlled trial (RCT); socioeconomic disparities; socioeconomic status (SES).

Conflict of interest statement

Financial Disclosure: Dr. Amy D. Waterman, PhD owns the intellectual property to the transplant education product Explore Transplant and has licensed it at no cost to a nonprofit, Health Literacy Media (HLM), which retains all sales revenue. Dr Waterman serves as an unpaid consultant to HLM to ensure the accuracy of educational content. The remaining authors declare that they have no relevant financial interests.

Copyright © 2019 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1.
Figure 1.
Study Flow Chart for Patient Selection
Figure 2.
Figure 2.
Pre- to Post Change in Transplant Knowledge Educational Condition – modified ITT sample ETH-EG = Explore Transplant Educator-Guided Condition; ETH-PG = Explore Transplant Patient-Guided Condition; SOC = Standard of Care education Condition ETH-EG vs. SOC p=0.02; ETH-PG vs. SOC p=0.01.
Figure 3.
Figure 3.
Differences in Reported Ability to Make an Informed Decision about Transplant Options at Post-Survey between Explore Transplant @ Home Conditions and Standard of Care – modified ITT Analysis OR: Odds ratio, KT: Kidney transplant, DDKT: Deceased donor kidney transplant, LDKT: Living donor kidney transplant, ETH-EG: Explore Transplant at Home – Educator Guided, ETH-PG: Explore Transplant at Home – Patient Guided, SOC: Standard of Care. Odds ratios estimate the difference in odds of reporting being able to make an informed decision about KT evaluation, DDKT, and LDKT for each ETH condition vs. standard of care. Rao-Scott χ2 p-values are given for each overall comparison.

References

    1. Saran R, Robinson B, Abbott KC, et al. US Renal Data System 2017 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis 2018; 71(3)(suppl 1):S1–S676.
    1. Neipp M, Karavul B, Jackobs S, et al. Quality of life in adult transplant recipients more than 15 years after kidney transplantation. Transplantation 2006;81(12): 1640–1644.
    1. Centers for Medicare & Medicaid Services. Medicare and Medicaid Programs; Conditions for Coverage for End-Stage Renal Disease Facilities; Final Rule. In: Department of Health and Human Services, ed. Vol 73 Baltimore, MD: Federal Register; 2008.
    1. Hall EC, James NT, Garonzik Wang JM, et al. Center-level factors and racial disparities in living donor kidney transplantation. Am J Kidney Dis 2012;59(6): 849–857.
    1. Waterman AD, Peipert JD, Hyland SS, McCabe MS, Schenk EA, Liu J. Modifiable patient characteristics and racial disparities in evaluation completion and living donor transplant. Clin J Am Soc Nephrol 2013;8(6): 995–1002.
    1. Alvaro EM, Siegel JT, Turcotte D, Lisha N, Crano WD, Dominick A. Living kidney donation among Hispanics: a qualitative examination of barriers and opportunities. Prog Transplant 2008;18(4): 243–250.
    1. Gordon EJ, Mullee JO, Ramirez DI, et al. Hispanic/Latino concerns about living kidney donation: a focus group study. Prog Transplant 2014;24(2): 152–162.
    1. Wachterman MW, McCarthy EP, Marcantonio ER, Ersek M. Mistrust, Misperceptions, and Miscommunication: A Qualitative Study of Preferences About Kidney Transplantation Among African Americans. Transplantation Proceedings 2015;47(2): 240–246.
    1. Johns TS, Estrella MM, Crews DC, et al. Neighborhood socioeconomic status, race, and mortality in young adult dialysis patients. J Am Soc Nephrol 2014;25(11): 2649–2657.
    1. Hinck BD, Naelitz BD, Jackson B, Howard M, Nowacki A, Modlin CS. Assessing Transplant Attitudes: Understanding Minority Men’s Perspectives on the Multifarious Barriers to Organ Donation. Journal of racial and ethnic health disparities 2017;4(4): 580–586.
    1. Axelrod DA, Dzebisashvili N, Schnitzler MA, et al. The interplay of socioeconomic status, distance to center, and interdonor service area travel on kidney transplant access and outcomes. Clin J Am Soc Nephrol 2010;5(12): 2276–2288.
    1. Herring AA, Woolhandler S, Himmelstein DU. Insurance status of U.S. organ donors and transplant recipients: the uninsured give, but rarely receive. Int J Health Serv 2008;38(4): 641–652.
    1. Laurentine KA, Bramstedt KA. Too poor for transplant: finance and insurance issues in transplant ethics. Prog Transplant 2010;20(2): 178–185.
    1. McSorley A-MM, Peipert JD, Gonzalez C, et al. Dialysis Providers’ Perceptions of Barriers to Transplant for Black and Low-Income Patients: A Mixed Methods Analysis Guided by the Socio-Ecological Model for Transplant. World Medical & Health Policy 2017;9(4): 399–416.
    1. Rodrigue JR, LaPointe Rudow D, Hays R, American Society of T. Living Donor Kidney Transplantation: Best Practices in Live Kidney Donation--Recommendations from a Consensus Conference. Clin J Am Soc Nephrol 2015;10(9): 1656–1657.
    1. Ruck JM, Zhou S, Thomas AG, et al. Electronic messaging and communication with living kidney donors. Clin Transplant 2018;32(2).
    1. Cole-Lewis H, Kershaw T. Text messaging as a tool for behavior change in disease prevention and management. Epidemiol Rev 2010;32(1): 56–69.
    1. Wang TC, Huang JL, Ho WC, Chiou AF. Effects of a supportive educational nursing care programme on fatigue and quality of life in patients with heart failure: a randomised controlled trial. European journal of cardiovascular nursing : journal of the Working Group on Cardiovascular Nursing of the European Society of Cardiology 2016;15(2): 157–167.
    1. Reilly-Spong M, Reibel D, Pearson T, Koppa P, Gross CR. Telephone-adapted mindfulness-based stress reduction (tMBSR) for patients awaiting kidney transplantation: Trial design, rationale and feasibility. Contemp Clin Trials 2015;42: 169–184.
    1. Vaiva G, Vaiva G, Ducrocq F, et al. Effect of telephone contact on further suicide attempts in patients discharged from an emergency department: randomised controlled study. BMJ 2006;332(7552): 1241–1245.
    1. Waterman AD, McSorley AM, Peipert JD, et al. Explore Transplant at Home: a randomized control trial of an educational intervention to increase transplant knowledge for Black and White socioeconomically disadvantaged dialysis patients. BMC Nephrol 2015;16: 150.
    1. Waterman AD, Robbins ML, Paiva AL, et al. Measuring kidney patients’ motivation to pursue living donor kidney transplant: development of stage of change, decisional balance and self-efficacy measures. J Health Psychol 2015;20(2): 210–221.
    1. Waterman AD, Robbins ML, Paiva AL, Hyland SS. Kidney patients’ intention to receive a deceased donor transplant: development of stage of change, decisional balance and self-efficacy measures. J Health Psychol 2010;15(3): 436–445.
    1. Guyatt GH, Feeny DH, Patrick DL. Measuring health-related quality of life. Ann Intern Med 1993;118(8): 622–629.
    1. LaVeist TA, Isaac LA, Williams KP. Mistrust of health care organizations is associated with underutilization of health services. Health Serv Res 2009;44(6): 2093–2105.
    1. Waterman AD, Peipert JD, Xiao H, et al. Education Strategies in Dialysis Centers Associated with Increased Transplant Wait-listing Rates. Transplantation 2019;In Press.
    1. Rodrigue JR, Paek MJ, Egbuna O, et al. Making house calls increases living donor inquiries and evaluations for blacks on the kidney transplant waiting list. Transplantation 2014;98(9): 979–986.
    1. Rodrigue JR, Cornell DL, Lin JK, Kaplan B, Howard RJ. Increasing live donor kidney transplantation: a randomized controlled trial of a home-based educational intervention. Am J Transplant 2007;7(2): 394–401.
    1. Boulware LE, Hill-Briggs F, Kraus ES, et al. Effectiveness of educational and social worker interventions to activate patients’ discussion and pursuit of preemptive living donor kidney transplantation: a randomized controlled trial. Am J Kidney Dis 2013;61(3): 476–486.

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