ASCENT (Allocation System Changes for Equality in kidNey Transplantation)

1R01MD01029001: An evaluation of racial disparities in access to kidney transplantation in new national kidney allocation policy

Description

The public health burden of kidney failure in the United States is substantial, exemplified by more than 600,000 end-stage renal disease (ESRD) patients. The primary treatments for kidney disease are dialysis or kidney transplantation. An intricate, multi-tiered national system regulates kidney disease care, reimbursement, and transplantation, creating barriers to overcoming the significant racial disparities that exist in transplantation, which is the most effective treatment for ESRD.

The federal Organ Procurement and Transplantation Network of the United Network for Organ Sharing oversees the allocation of all deceased donor organs in the U.S. On Dec. 4, 2014, a major change to the allocation policy was implemented that is expected to impact racial disparities in transplantation access. We propose to study the impact of the natural experiment offered by enactment of this new kidney allocation policy on reducing disparities in the key steps of referral for transplant evaluation, wait listing, and transplantation, each of which have complexities for measurement at the local and national level.

To impact disparities reduction at the service delivery level, we will also use national data to develop and then disseminate a systems-level practice of providing feedback to dialysis centers about their transplant performance. Ideally, this process will improve overall wait listing rates and decrease disparities in kidney transplantation.

Specific Aims

1. To test the hypothesis that the new kidney allocation policy will lead to a reduction in disparities in transplantation at one year, we will prospectively examine the impact of the policy changes on racial disparities in the key steps in the transplant process post- vs. pre- allocation: (a) referral from the dialysis facility for transplant evaluation in the Southeast, where we have access to this unique data, and (b) wait listing and transplantation in the U.S.

2. To evaluate the impact of a systems-level approach wherein tailored transplant performance feedback and education about the kidney allocation policy is provided, we will conduct a multicomponent, clinical effectiveness-implementation study among 750 U.S. dialysis facilities which treat >50,000 dialysis patients. We anticipate that increasing provider knowledge will reduce disparities in transplant wait listing. The long-term impact of this application will be to influence the way organs are allocated in the U.S. in order to ensure equitability through better analysis of policy and dissemination of best practices at the health systems level.

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