Background
Methods
Intervention and process evaluation development
Required Intervention Activities (n = 9) |
Attending facility in-service orientation to quality improvement transplant project |
Establishing dialysis facility quality improvement plan |
Formation of patient and family advisory group for monthly meetings |
Establishing peer mentoring program |
Educational webinars for dialysis facility leadership and staff |
Standard quality improvement activities and monthly monitoring of transplant referral and evaluation data |
Establishing patient and family education programs |
Planning a facility-wide movie night: Living ACTS [46] |
Completing 5-Diamond Patient Safety module on transplantation [12] |
Optional Intervention Activities (n = 5) |
Kidney transplantation bulletin board |
Distribution of “A Patient’s Guide to Kidney Transplant” [24] |
Conduct a Transplant Education Month |
Attend a “Explore Transplant” Symposium [47] |
Distribution of Kidney Transplant Toolkit |
Data collection
Inclusion/exclusion criteria
Data analysis
Dimension | Process Evaluation Questions | Measurement |
---|---|---|
Fidelity
| To what extent was the intervention delivered as planned? | Facility-level participation (Y/N) in each required and optional intervention component and in all required and optional intervention activitiesa Composite fidelity index of the number of intervention components completed (0–14) |
Sustainability
| To what extent are intervention activities perceived as helpful? To what extent are dialysis facilities willing to continue intervention activities indefinitely? How can the intervention be improved for dissemination? | Staff-perceived helpfulness of intervention activities (Likert scale) Willingness to continue intervention activities (yes/no) based on perceived helpfulness Open-ended questions regarding suggestions for improving select intervention activities |
Reach
| To what extent did its intended audience receive the intervention? | Proportion of patients receiving each patient-level intervention component and the full multicomponent interventionb |
Context
| What barriers may prevent patients at intervention facilities from beginning or completing the transplant evaluation process? What non-intervention educational materials or resources were provided to patients at intervention facilities? | Itemized checklist at end of questionnaire Facility-level distribution (Y/N) of non-RaDIANT educational resources to dialysis patients |
Linking process data to intervention outcomes
| To what extent does facility level referral for kidney transplantation vary by implementation fidelity among intervention facilities pre- and post-intervention? | Association between fidelity index (0–14) and mean difference in proportion of patients referred for kidney transplantation in the 2014 intervention year |
Results
Study population
Characteristics | n = 65 |
---|---|
Survey Population Characteristics | |
Staff rolea | |
% Social Worker | 50.8 |
% Clinic (nurse) manager | 15.4 |
% Facility administrator | 10.8 |
% Administrative assistant | 4.6 |
% Nurse | 4.6 |
Facility Characteristicsb | |
No. of patients per facility, mean ± SD | 44.6 ± 24.3 |
No. of staff, mean ± SD | 9.4 ± 5.6 |
% For profit | 88.1 |
% crude referral in lowest 50th percentile | 64.6 |
% within-facility racial disparity in kidney transplant referrals at baseline (2013) | 35.4 |
Characteristics of patients within facilitiesb | |
Age (years), mean ± SD | 60.2 ± 6.2 |
% White | 32.8 |
% Black | 65.8 |
% Hispanic | 2.0 |
% Hemodialysis modality | 94.8 |
% Uninsured at ESRD start | 10.1 |
% Medicaid only at ESRD start | 12.9 |
% Unemployed | 69.2 |
Average time on dialysis (years), mean ± SD | 5.0 ± 1.2 |
% Receiving no pre-ESRD nephrology care | 25.8 |
% Not informed of transplant options | 3.2 |
% With diabetes | 54.4 |
% With hypertension | 92.2 |
% With arteriovenous fistula | 29.9 |
Average count of comorbidities, mean ± SD | 2.8 ± 0.8 |
Fidelity
Required Intervention Activities (n = 9) | Staff- reported facility participation at study end (n = 65 facilities), n (%) |
In-service staff orientation | 60 (92.3) |
Standard QI activities | 60 (92.3) |
Educational webinars | 60 (92.3) |
Quality improvement plan | 58 (89.2) |
5 Diamond module | 57 (87.7) |
Patient and family education programs | 54 (83.1) |
Movie Night: Living ACTS | 52 (80.0) |
Patient and family advisory group | 46 (70.8) |
Peer mentoring program | 44 (67.7) |
Optional Intervention Activities (n = 5) | |
A Patient’s Guide to Kidney Transplant | 55 (84.6) |
Transplant bulletin board/poster | 49 (75.4) |
Kidney Transplant toolkit | 49 (75.4) |
Transplant symposium | 42 (64.6) |
Transplant Education Month | 37 (56.9) |
Fidelity Indexb, mean ± SD | 11.1 ± 3.4 |
Sustainability
Intervention activitya | Perceived helpfulness of intervention activityb | Willingness to continuing intervention activityb,c |
---|---|---|
% | % | |
In-service staff orientation | 85.0 | 54.9 |
Educational webinars | 78.3 | 12.8 |
Patient and family education programs | 74.1 | 60.0 |
Quality improvement plan | 70.7 | 14.6 |
5 Diamond Patient Safety module | 66.7 | 0 |
Peer mentoring program | 65.9 | 69.0 |
Movie Night: Living ACTS | 63.5 | 36.4 |
Standard QI activities | 53.3 | 50.0 |
Patient and family advisory group | 47.8 | 31.8 |
Reach
Context
Staff-reported barrier, n (%) | |
---|---|
Logistical Barriers | |
Lack of transportation to the transplant center | 37 (56.9) |
Distance to transplant center | 33 (50.8) |
Timing of appointment (i.e., conflicts with work or dialysis schedule) | 10 (15.4) |
Emotional/Motivational Barriers | |
Evaluation doesn’t seem urgent as patient does not mind dialysis | 35 (53.9) |
Lost interest in continuing the evaluation process after initial appointment | 35 (53.9) |
Anxiety about appointment or transplant procedure itself | 26 (40) |
Knowledge Barriers | |
Low health literacy | 33 (50.8) |
Lack of understanding about the transplant process itself | 27 (41.5) |
Low literacy | 25 (38.5) |
Health Barriers | |
Cardiovascular disease | 36 (55.4) |
Decreased functional status/needing assistance with daily activities | 29 (44.6) |
Diabetes | 21 (32.3) |
Financial Barriers | |
Cannot afford medications post-transplant | 47 (72.3) |
Patient perceived fundraising requirements | 39 (60) |
Cannot afford co-pay | 30 (46.2) |
Demographic Barriers | |
Socioeconomic status | 48 (73.9) |
Age | 27 (41.5) |
Race | 8 (12.3) |