Trained navigators may improve access to transplantation for disadvantaged patients

In a recent study, a trained navigator who provided guidance to disadvantaged patients with kidney failure helped increase access to the transplant waitlist among patients who needed a longer time to get through the transplant evaluation process. The intervention, which is described in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN), may help improve patients' chances of receiving potentially life-saving kidney transplants.

Kidney transplantation is the optimal treatment for most patients with kidney failure; however, only about 13% of US kidney failure patients are waitlisted for transplantation. Racial and socioeconomic disparities exist in patients' likelihood of completing the transplant process. Rachel Patzer, PhD, MPH, of the Emory University School of Medicine, and her colleagues wondered whether a patient navigator may help improve access to the kidney transplant waiting list, as well as reduce the time from when patients are referred for transplantation by dialysis facilities to when they are waitlisted.

The researchers conducted a randomized controlled trial of 401 patients referred for kidney transplant evaluation at a single center. For half of the patients, a trained navigator with a degree in social work assisted participants from referral through waitlisting decision, with the goal of increasing waitlisting and decreasing time from referral to waitlisting.

Waitlisting was not significantly different among patients who received the intervention (32%) vs. control patients (26%) overall, and time from referral to waitlisting was actually 126 days longer for intervention patients. The effectiveness of the navigator varied from early (<500 days from referral) to late (?500 days) follow-up, however: while no difference in waitlisting was observed among intervention (50%) vs. control (50%) patients in the early period, intervention patients were 3.3 times more likely to be waitlisted after 500 days (75% vs. 25%). There were no significant differences in intervention vs. control patients who started transplant evaluation (85% vs. 79%) or completed evaluation (58% vs. 51%); however, intervention patients had more living donor inquiries (18% vs. 10%), meaning that candidates' friends/family members called transplant centers to inquire about testing to see if they might be donors.

The increased time from referral to waitlisting for patients who received the intervention may relate to the high needs of the study population, who might not otherwise have been waitlisted without a patient navigator due to the additional time needed to complete various medical tests and follow-up requirements compared with patients who waitlisted within the first 500 days.

"The kidney transplant evaluation process is quite complicated and lengthy, and is a substantial barrier for some patients to complete—particularly patients who may be good medical candidates with potential living donors but who may have socioeconomic, cultural, or other barriers that must be addressed to navigate the transplant process," said Dr. Patzer. "This study found that a social worker navigator who worked with patients to assist and motivate them in completing tests and attending appointments helped to increase waitlisting for those patients who took more than 500 days to get through the process." In future work, the researchers would like to test whether combining a navigator with other educational or outreach interventions could help improve access to care for such patients.

In an accompanying editorial, Amy Waterman, PhD (David Geffen School of Medicine at UCLA) and Jennifer Beaumont, MS (Terasaki Research Institute) noted that the field of kidney transplantation must continue to look to a multi-faceted intervention approach to resolve disparities and increase wait-listing and kidney transplantation for high-risk patients. "Interventions need to address every level of the kidney transplant system—providers, healthcare systems, patients, family, and community at-large," they wrote.

Also, an accompanying Patient Voice editorial provides the perspective of Richard Knight, MBA, an Adjunct Professor at Bowie State University and a former hemodialysis patient who received a kidney transplant approximately 11 years ago. "I applaud the efforts made to build upon the work of others to develop an efficient navigator process for the patients who statistically fare the worst in obtaining a kidney transplant," he wrote. "I also applaud the greater use of fellow patients in the process, because I know first-hand that the well-informed guidance of a patient peer has far more impact on my thinking than professionals alone who have not made the journey of kidney disease."