Referral for Kidney Transplant, Specifically Living Donor Transplant,
In Adult (Age 18-65 years) Chronic Hemodialysis Patients
An ESRD Network 5 Quality Improvement Project
Project Background and Description: In 1999, the Network 5 Medical Review Board Transplant Subcommittee developed and implemented a quality improvement project designed to deliver current transplant information to dialysis providers. Review of Network 5 transplant rates, USRDS Standardized Transplantation Ratios (STRs) and transplant referral patterns indicated that an opportunity existed to improve patient access to transplant in the Network. Due to the static nature of cadaveric organ donation, this educational project focused on delivery of living donor kidney transplant information.
The outcome objective was to demonstrate increased numbers of patients referred for and/or receiving living donor kidney transplant. CMS regulations require dialysis providers to provide transplant information to patients through the development and annual review of the patient’s long-term care plan. Facility implementation of these regulations may vary in selection of educational tools, method of presentation, (i.e. staff counseling, written, and/or video format) and scope and frequency of presentation. It was theorized that delivery of standardized information to all medically eligible patients on a specified schedule would improve access to transplant for racial, gender and/or economic groups that currently are perceived as having reduced access to this renal replacement therapy.
Methodology: Adult hemodialysis patients and unit staff in selected outpatient dialysis facilities were the target population based on MARC aggregated data for 1992-1998. Analysis and treading of these data by the Harvard School of Public Health resulted in recommendation of eighteen (18) participant facilities. Facilities with a patient census < 30 adult patients were excluded from selection review. Twelve (12) remaining facilities were grouped into a four-way randomization model stratified into three groups by geographic location and patient census. Blind draw determined the participation category of each facility. Participation categories for the intervention phase of the project included:
· Control #1: No intervention, monitor facility performance
· Control #2: Facility submits monthly transplant report, September 1999-February 2000 (track transplant status of newly diagnosed Network 5 ESRD patients)
· Intervention #1: One-day educational site visit by intervention team
· Intervention #2: One-day educational site visit by intervention team; facility submits monthly transplant report, September 1999-February 2000
Using an educational tool kit developed for the project, a team composed of a Network staff member, a transplant coordinator, and a transplant recipient or physician (as available) conducted in-service training sessions in project intervention facilities during September 1999. The tool kit was provided to facility staff for future in-service educational use. Network 5 Transplant Center practice patterns for the previous twelve-month period, and facility-specific transplant statistics were measured using evaluation tools adapted from The Partnership for Organ Donation (#OP3-RMG293W-4 questionnaire).
Intermediate Outcome: MARC conducted preliminary comparison of the 1998 and 1999 Transplant Status Survey in February 2000. Status 1 designates patients waitlisted for cadaveric transplant, or scheduled for living donor transplant and Status 2 are patients referred for medical evaluation for cadaveric or living donor transplant. All project intervention facilities showed an increased number of patients with combined status 1 and 2, with a mean increase of 64.5% (range 4.0% to 139.6%). Control facilities showed an increased number of patients with combined status 1 and 2 at a lower rate (mean percentage of change was 24.4%, with a range from 70.9% to 100.2%). Documentation of the process used by the control unit with 100.2% change revealed that a significant staff turn over occurred between 1998-1999 resulting in an increased focus on presentation of transplant as a treatment option.
Long Term Outcome: Final measurement of project indicators will be completed at year-end 2000. The Transplant Subcommittee remains committed to the theory that increased educational efforts will result in improved patient access to transplant and increased numbers of patients receiving living donor transplant. December 1999 articles featured in the New England Journal of Medicine again raised concern regarding reduced access to transplant for some patient groups, and raised questions regarding referral trends in non-profit versus for-profit dialysis facilities. It is the Subcommittee’s hope that a standardized presentation of transplant information will be developed for use on the Network and national levels to facilitate improved patient outcome for the ESRD population.
Addendum March 2001:
Preliminary comparison and analysis of the 2000 Transplant Status Survey were performed by MARC for the 12 Virginia facilities that participated as Intervention and Control units for the Living Donor Kidney Transplant Educational Project. No statistically significant improvement was demonstrated in the intervention units based on p-value using Chi Square testing. Comparison of intervention facility data 1998 2000 showed five of six facilities had an increased number of patients with combined status 1 and 2, with a mean increase of 25.1% (range 59.2% to 73.4%). Comparison of control facility data 1998 2000 showed five of six facilities had an increased number of patients with combined status 1 and 2, with a mean increase of 34.5% (range 25.9% to 67.7%). Facility Transplant Questionnaires (12) and Transplant Center Questionnaires (14) will be computerized and compared to baseline project data during April 2001.