Disparities in the Quality and Provision of Kidney Transplant Education

Abstract

Introduction: The nephrologist is often the first provider to educate ESRD patients about kidney transplant (KT). Disparities in the quality and provision of KT education might contribute to disparities in access to transplant (ATT). The goals of this study were to (1) describe nephrologists' attitudes and practices regarding KT education, (2) characterize the provision of KT education by nephrologists nationally and, (3) analyze associations between KT education and ATT. Methods: We surveyed 906 nephrologists regarding KT education attitudes and practices. We then analyzed the provision of transplant education among all incident ESRD patients in the United States between 2005 and 2007 as captured in the United States Renal Data System (USRDS). Results: Most survey respondents (81%) felt the ideal time to spend on transplant education was >20mins, but only 43% reported actually doing so. Spending >20mins was associated with covering more topics, having one-on-one and repeated conversations, involving families in discussions, and initiating discussions at CKD-stage 4. Nationally, 30.1% of ESRD patients were not informed about transplant at ESRD-onset, for reasons reported by providers as follows: 42.1% unassessed, 30.4% medically unfit, 16.9% unsuitable due to age, 3.1% psychologically unfit, and 1.5% declined counsel. Patients at for-profit centers were 20% more likely to be unassessed. This finding was supported by survey data; nephrologists at for-profit centers were significantly less likely to spend >20mins on KT education (RR=0.89, 95%CI:0.80-0.99) or involve families (RR=0.57, 95%CI:0.38-0.87). Furthermore, they reported that fewer of their patients received transplant counseling (RR=0.58, 95%CI:0.37-0.96), initiated transplant discussions (RR=0.58, 95%CI:0.38-0.88), or were eligible for transplantation (RR=0.45, 95%CI:0.30-0.68). In the national sample, uninformed patients had a 53% lower rate of ATT, a disparity that persisted in the subgroup of uninformed patients who were simply unassessed (Figure 1).[Figure 1]Conclusions: Disparities in ATT may be partially explained by disparities in the quality and provision of KT education; dialysis centers should ensure this critical intervention is offered to patients in an equitable and timely manner.