Two New R01-Funded Emory Collaborations Will Develop Methods of Alleviating Kidney Transplant Disparities
Rachel Patzer, PhD, director of the Emory Transplant Center Health Services and Outcomes Research Program, is co-principal investigator on two new NIH R01 grants that deal with disparities issues associated with kidney transplant. She will work with Emory transplant surgeon Andrew Adams, MD, PhD, and Georgia Institute of Technology computing professor Jimeng Sun, PhD, on one of the projects, and on the other, her collaborator will be Kimberly Jacob Arriola, PhD, MPH, a behavioral scientist and epidemiologist from the Rollins School of Public Health.
The grant with Dr. Adams will address the higher numbers of post-transplant hospitalizations that happen to African American (AA) and low socioeconomic status (SES) patients compared to white patients. Post-transplant hospitalizations are associated with heightened rates of graft loss and poor quality of life. The attempt to reverse this trend is especially critical for transplant centers in the Southeast, which treat the greatest number of AA transplant recipients in the U.S., and where poverty exacerbates care for end-stage renal disease (ESRD) patients.
It has been shown that more than 50 percent of kidney transplant surgical readmissions may be preventable. Drs. Patzer and Adams believe that using a big data, predictive analytics approach of developing, validating, and putting revised risk prediction models into the hands of clinicians could do much to identify patients in real-time who are at high risk for hospitalization following kidney transplantation.
"Current risk prediction models are intended to alert providers and researchers to the modifiable factors that can reduce the likelihood of post-surgical hospitalization, but are limited by outdated statistical approaches and reliance on structured data that does not capture important patient-centered risk factors and social determinants of health known to impact all levels of ESRD care," says Dr. Patzer. "We will work with Dr. Sun and his Georgia Tech team to develop and validate dynamic predictive models that incorporate changes in clinical data over time, such as worsening of diabetes or hypertension, as well as rich sources of data from clinical notes so that multidisciplinary clinical care teams can better identify transplant recipients at high risk for post-transplant hospitalization."
To populate the new model's data core, Drs. Patzer and Adams plan to build upon their previously funded work utilizing the Emory Transplant Center's Data Mart, a consolidated, highly comprehensive repository of pre-transplant, peri-operative, and post-transplant data from multiple sources for querying and visualization, and then apply advanced predictive analytics to information from 3,500 transplant recipients over a 12 year period. The data they amass will be used to develop and evaluate updated, dynamic risk prediction models for hospitalization within 30 days, six months, and one year after transplant.
The team will then design an electronic hospitalization risk dashboard that will aid in clinical decision-making and guide use of scarce resources for patients at high risk for post-transplant hospitalization. Predictor variables identified in the analytics process will be extracted in less than 24 hours from the electronic medical record, transmitted to a statistical software program, and automatically loaded back into the Data Mart to support a clinical, electronic dashboard to identify high risk patients in real-time.
By using a community-based participatory research approach based on such methods as stakeholder meetings and interviews with patients and providers, the team will also engage clinicians, patients, and community partners on using existing resources to reduce hospitalization.
"Once clinicians can identify and risk stratify patients in real-time using the new dashboard, they should be able to identify and target patients at highest risk for hospitalization at each clinical encounter, and allocate individualized, supportive interventions to prevent or prepare patients for hospitalization," says Dr. Adams. "The application of this approach to those at highest risk may reduce disparities post-transplant."
Other Emory co-investigators on this project include transplant surgeon-scientists Raymond Lynch, MD, and Christian Larsen, MD, DPhil, health services researcher Laura Plantinga, PhD, of the Division of Renal Medicine, and implementation science expert Cam Escoffery, PhD, MPH, of the Rollins School of Public Health.
For the second grant, Dr. Patzer and Dr. Arriola will focus on the pervasive racial disparities that exist in access to living donor kidney transplant (LDKT), with white ESRD patients being four times more likely to receive an LDKT than AA ESRD patients. Their multi-center randomized controlled trial will seek to determine whether coupling a systems-level intervention known as Transplant Referral Exchange, or T-REX, with a web-based version of the culturally-sensitive educational package Living ACTS: About Choices in Transplantation and Sharing, will be effective at increasing living donor kidney transplant among AA patients. T-REX is an electronic referral software program previously developed by the research team that enhances communication between dialysis facility and transplant center clinicians.
The first step of the study will be to develop the online format of Living ACTS, which was originally created by Dr. Arriola with other Emory colleagues, and currently consists of a DVD and educational booklet. Once the site is posted, it will be evaluated among approximately 800 AA ESRD patients who will be randomized to visit either the Living ACTS website or a control site with an embedded, standard educational video. The percentage of each group that receives at least one inquiry from a potential living donor will then be compared. The four transplant centers participating in the study are the Emory Transplant Center, Piedmont Hospital Transplant Institute, Georgia Regents Medical Center, and the Medical University of South Carolina.
"This is an important collaboration of four transplant centers that have among the highest proportion of African American patients awaiting kidney transplantation, and yet have low rates of living donor transplantation," says Dr. Patzer. "We anticipate that results will offer us additional insights and answers regarding health disparities in this population."