A randomized trial of an educational and quality intervention in southeastern U.S. dialysis facilities found that while overall transplant referral rates declined across both intervention and control groups, the intervention slowed (but didn't reverse) this decline in some populations. White patients in intervention facilities saw improved referral rates, but the intervention did not significantly improve referral rates for Black patients, despite being designed to address racial disparities.
Kidney transplantation remains the gold standard renal replacement therapy for patients with end-stage kidney disease, yet significant racial and socioeconomic disparities in access persist across the United States. The southeastern region has historically recorded some of the nation's lowest transplantation rates and most pronounced disparities. To address this, researchers designed a multicomponent intervention delivered to dialysis facilities across Georgia, North Carolina, and South Carolina and evaluated its effectiveness through a randomized controlled trial.
The trial randomized 440 dialysis facilities to either receive the Reducing Disparities in Access to Kidney Transplantation Regional (RDAK) intervention, which included educational programs and quality improvement components, or standard care. The study tracked 25,586 patients with end-stage kidney disease across these facilities. Researchers measured three primary outcomes: transplant referral within 1 year of dialysis initiation, evaluation start within 6 months of referral, and waitlisting within 1 year of evaluation start. The follow-up period was 1 year post-intervention.
A counterintuitive finding emerged: referral rates declined in both intervention and control facilities during the study period, mirroring national trends. Control facilities experienced a larger decline (from 11.2% to 9.2%) compared to intervention facilities (11.2% to 10.5%), suggesting the intervention at least partially mitigated declining rates. However, the critical question for disparities research yielded a complex answer. Among White patients, those treated in intervention facilities showed a statistically significant increase in referral likelihood compared to control facilities (odds ratio 1.24). In stark contrast, Black patients showed no significant difference in referral likelihood between intervention and control facilities (odds ratio 1.12, which was not statistically significant). This differential effect suggests the intervention may have been more effective for some populations than others, despite being designed to reduce disparities.
Implementation data provided context for these findings. A post-implementation survey of 220 staff members and semistructured interviews with facility leadership identified several barriers to effectiveness. Staff emphasized the importance of tailored interventions that account for facility-specific contexts, the necessity of federal policy mandates to drive change, and practical challenges inherent in conducting large pragmatic trials within complex healthcare systems. The researchers concluded that while the intervention did not achieve its primary goal of reducing disparities, it did slow national decline trends in some groups, warranting continued investigation into optimized intervention designs.
If you or a family member is beginning dialysis in the southeastern United States, this study illuminates both the landscape and limitations of current efforts to improve transplant access. The finding that referral rates are declining nationally, even with targeted interventions, underscores that systemic barriers extend beyond facility-level educational programs. The differential benefit observed between racial groups suggests that one-size-fits-all interventions may not adequately address the structural and institutional factors that contribute to disparities in transplant access.
The research highlights that future improvements likely require interventions that go beyond education and quality metrics. This could include stronger federal requirements for transplant referral and evaluation, facility-level accountability measures, and approaches that specifically target barriers experienced by underrepresented populations in transplantation. If you are exploring transplantation options, advocating for referral and evaluation remains critical, as these steps are prerequisite for waitlisting and access to transplant surgery.
| Characteristic | Details |
|---|---|
| Study type | Randomized controlled trial |
| Sample size | 440 dialysis facilities; 25,586 patients with ESKD |
| Study population | Patients with end-stage kidney disease initiating dialysis in Georgia, North Carolina, and South Carolina |
| Intervention | Multicomponent educational and quality improvement program (RDAK intervention) |
| Control | Standard dialysis care and practices |
| Primary outcome | Change in transplant referral rate within 1 year of dialysis start |
| Secondary outcomes | Evaluation start within 6 months of referral; waitlisting within 1 year of evaluation start |
| Key finding | Intervention slowed decline in referrals overall, but showed differential effects by race; significant benefit for White patients (OR 1.24) but not for Black patients (OR 1.12, not significant) |
| Implementation data | Post-intervention survey (N=220); semistructured interviews (N=4) |
| Journal | Clinical Journal of the American Society of Nephrology |
| Publication year | 2024 |
National Institutes of Health, National Center for Biotechnology Information. "Reducing Disparities in Access to Kidney Transplantation Regional Study: A Randomized Trial in the Southeastern United States." *Clinical Journal of the American Society of Nephrology*, 2024. PubMed ID: 39671258. https://pubmed.ncbi.nlm.nih.gov/39671258/
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| NCT02389387 |