Division of Transplantation, Department of Surgery and.
Emory Transplant Center, Atlanta, Georgia; and.
Clin J Am Soc Nephrol. 2018 Apr 6;13(4):620-627. doi: 10.2215/CJN.08600817. Epub 2018 Mar 26.
Barriers exist in access to kidney transplantation, where minority and patients with low socioeconomic status are less likely to complete transplant evaluation. The purpose of this study was to examine the effectiveness of a transplant center-based patient navigator in helping patients at high risk of dropping out of the transplant evaluation process access the kidney transplant waiting list.
DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS: We conducted a randomized, controlled trial of 401 patients (=196 intervention and =205 control) referred for kidney transplant evaluation (January 2013 to August 2014; followed through May 2016) at a single center. A trained navigator assisted intervention participants from referral to waitlisting decision to increase waitlisting (primary outcome) and decrease time from referral to waitlisting (secondary outcome). Time-dependent Cox proportional hazards models were used to determine differences in waitlisting between intervention and control patients.
At study end, waitlisting was not significantly different among intervention (32%) versus control (26%) patients overall (=0.17), and time from referral to waitlisting was 126 days longer for intervention patients. However, the effectiveness of the navigator varied from early (<500 days from referral) to late (≥500 days) follow-up. Although no difference in waitlisting was observed among intervention (50%) versus control (50%) patients in the early period (hazard ratio, 1.03; 95% confidence interval, 0.69 to 1.53), intervention patients were 3.3 times more likely to be waitlisted after 500 days (75% versus 25%; hazard ratio, 3.31; 95% confidence interval, 1.20 to 9.12). There were no significant differences in intervention versus control patients who started evaluation (85% versus 79%; =0.11) or completed evaluation (58% versus 51%; =0.14); however, intervention patients had more living donor inquiries (18% versus 10%; =0.03).
A transplant center-based navigator targeting disadvantaged patients improved waitlisting but not until after 500 days of follow-up. However, the absolute effect was relatively small.
在获得肾脏移植的过程中存在障碍，少数民族和社会经济地位较低的患者完成移植评估的可能性较小。本研究的目的是检验移植中心设立的患者导航员在帮助处于高脱落风险的患者进入肾脏移植等待名单方面的有效性。
设计、地点、参与者和测量方法：我们在一个单一中心进行了一项随机、对照试验，共纳入 401 名患者（196 名干预组和 205 名对照组），他们在 2013 年 1 月至 2014 年 8 月（随访至 2016 年 5 月）期间被推荐进行肾脏移植评估。一名经过培训的导航员从推荐到等待名单决策期间协助干预组患者，以增加等待名单（主要结局）和减少从推荐到等待名单的时间（次要结局）。使用时间依赖性 Cox 比例风险模型来确定干预组和对照组患者之间等待名单的差异。
研究结束时，干预组（32%）与对照组（26%）患者的总体等待名单率无显著差异（=0.17），干预组患者从推荐到等待名单的时间延长了 126 天。然而，导航员的效果在早期（推荐后<500 天）和晚期（推荐后≥500 天）随访中存在差异。尽管在早期阶段，干预组（50%）与对照组（50%）患者的等待名单率无差异（风险比，1.03；95%置信区间，0.69 至 1.53），但在 500 天后，干预组患者等待名单的可能性是对照组的 3.3 倍（75%对 25%；风险比，3.31；95%置信区间，1.20 至 9.12）。开始评估的干预组与对照组患者（85%对 79%；=0.11）或完成评估的患者（58%对 51%；=0.14）之间没有显著差异；然而，干预组患者的活体供者查询更多（18%对 10%；=0.03）。
针对弱势患者的移植中心设立的导航员提高了等待名单率，但直到随访 500 天后才会提高。然而，绝对效果相对较小。
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