BACKGROUND The Southeastern United States (US) has among the lowest rates of kidney transplantation nationally and has documented racial and socioeconomic disparities in transplant access. We assessed the effectiveness and implementation of a multi-component intervention aimed at increasing access and reducing disparities in access to early transplant steps in Georgia (GA), North Carolina (NC), and South Carolina (SC). METHODS The Reducing Disparities in Access to Kidney Transplantation (RaDIANT) Regional Study randomized 440 dialysis facilities in GA, NC, and SC to receive the RaDIANT Regional educational and quality intervention or standard of care in 2018. The primary outcome was a change in dialysis facility-level transplant referral within one year of dialysis start post-intervention, with secondary outcomes examining changes in evaluation start within six months of referral and waitlisting within one year of evaluation start. A process evaluation included a post-implementation survey (N=220) and semi-structured interviews of staff (N=4). Generalized linear mixed-effects models assessed intervention effectiveness overall and in race subgroups. RESULTS Among the 25,586 patients with ESKD treated in 440 dialysis facilities, referral rates decreased across both intervention arms one-year post-intervention; however, a greater decrease in referrals was observed among control (11.2% to 9.2%) vs. intervention (11.2% to 10.5%) facilities. We observed no significant difference in the likelihood of referral among Black patients in intervention versus control facilities post-intervention (adjusted odds ratio [OR]: 1.12, 95% confidence interval [CI]: 0.94-1.33); however, a significant increase in referral was observed among White patients in intervention facilities post-intervention (OR: 1.24, 95% CI: 1.02-1.51). Interviews highlighted the importance of tailored interventions, federal mandates, and implementation challenges for large pragmatic trials. CONCLUSION Post-intervention declines in referral mirror national trends; however, these declines were less for some groups receiving the intervention, warranting long-term follow-up. These findings provide important context for future modification and scale-up of multi-level, multicomponent interventions in dialysis settings.

中文翻译：

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减少肾移植可及性差异 （RaDIANT） 区域研究：美国东南部的一项随机试验


背景 美国东南部 （US） 是全国肾移植率最低的国家之一，并且记录了移植可及性的种族和社会经济差异。我们评估了佐治亚州 （GA） 、北卡罗来纳州 （NC） 和南卡罗来纳州 （SC） 旨在增加早期移植步骤可及性和减少可及性差异的多组分干预的有效性和实施情况。方法 减少肾移植可及性差异 （RaDIANT） 区域研究在 2018 年随机分配了佐治亚州、北卡罗来纳州和南卡罗来纳州的 440 家透析机构接受 RaDIANT 区域教育和质量干预或护理标准。主要结局是干预后透析开始后 1 年内透析机构级移植转诊的变化，次要结局检查转诊后 6 个月内评估开始的变化和评估开始后 1 年内进入候补名单的变化。过程评估包括实施后调查 （N=220） 和对员工的半结构化访谈 （N=4）。广义线性混合效应模型评估了总体和种族亚组的干预效果。结果在 440 家透析机构接受治疗的 25,586 名 ESKD 患者中，干预后一年内两个干预组的转诊率都有所下降;然而，与干预 （11.2% 至 10.5%） 机构相比，对照组 （11.2% 至 9.2%） 的转诊减少幅度更大。我们观察到干预后黑人患者与对照组患者转诊的可能性没有显著差异（调整后比值比 [OR]：1.12,95% 置信区间 [CI]：0.94-1。33);然而，在干预后干预机构的白人患者中观察到转诊率显着增加 （OR： 1.24,95% CI： 1.02-1.51）。访谈强调了量身定制的干预措施、联邦授权和大型实用试验实施挑战的重要性。结论 干预后转诊率下降反映了全国趋势;然而，对于一些接受干预的群体来说，这些下降较少，需要长期随访。这些发现为未来在透析环境中修改和扩大多水平、多组分干预提供了重要的背景。