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

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).

Figure 1.

Study Flow Chart for Patient Selection

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.

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.