Studies of quality improvement interventions at dialysis facilities have shown improvements in end-stage renal disease (ESRD) outcomes and in quality of life of patients with ESRD. However, according to Reem E. Hamoda, MD, and colleagues, those studies focused on effect size in evaluating the success of the intervention, with few data on why the intervention worked or whether the intervention lent itself to reproducibility in varied contexts.
The RADIANT (Reducing Disparities in Access to Kidney Transplantation) Community Study, a randomized pragmatic trial designed to examine the effectiveness of a multicomponent, 1-year quality improvement intervention conducted in 2014. The program was designed to increase referral for kidney transplant evaluation and reduce racial disparities in referrals from dialysis facilities in Georgia, the state with the lowest transplant rates in the United States.
At the end of the intervention period (January-December 2014), the researchers conducted a process evaluation that measured the fidelity, sustainability, reach, and context of the RADIANT Community intervention. Results of the evaluation were reported in BMC Nephrology [2018; doi: 10.1186/s12882-017-0807-z].
The evaluation consisted of a 20-item survey administered to the staff involved with transplant education in 67 dialysis facilities randomized to participate in intervention activities. Of the 67 facilities, 97% had at least one staff member complete the questionnaire; a total of 94 staff members completed the survey. Following application of inclusion and exclusion criteria, 65 facilities were represented in the survey population.
To measure fidelity, the survey asked, To what extent was the intervention delivered as planned?. Of the 65 facilities represented, 33 (50.8%) reported they fully adhered to the intervention requirements; 29 of those participated in all intervention activities including all five optional activities.
The required intervention activities implemented most often included organizing an in-service staff orientation (92.3%), participation in standard quality improvement and monthly monitoring activities (92.3%), and participation in staff educational webinars (92.2%). Of the optional intervention activities, the top three were distribution of “A Patient’s Guide to Kidney Transplant” (84.6%), creation of a transplant education bulletin board or poster (75.4%), and creation of a comprehensive kidney transplant toolkit (75.4%).
Questions related to sustainability were, To what extent are intervention activities perceived as helpful? To what extent are dialysis facilities wiling to continue intervention activities indefinitely? and How can the intervention be improved for dissemination?. Nearly two thirds of facilities said the majority (≥5) of the intervention activities were helpful or very helpful; 22.0% said all of the required interventions were helpful or very helpful. No facility reported being willing to continue all required activities, however, 90.8% were willing to continue at least one activity indefinitely. When asked about possible improvements, staff often mentioned including webinars related to financial barriers to kidney transplantation.
Reach was investigated with the question, To what extent did its intended audience receive the intervention?. During the intervention year (2014), an estimated 4166 patients received care at an intervention facility; of those, 50.9% received care at facilities that adhered to the full RADIANT intervention.
To assess context, the survey asked, What barriers may prevent patients at intervention facilities from beginning or completing the transplant evaluation process? and What non-intervention educational materials or resources were provided to patients at intervention facilities?. Most frequently reported barriers to starting or completing a transplant evaluation once referred that were financially related, such as patients’ socioeconomic status (73.9%), inability to afford medications following transplantation (72.3%), and patient-perceived fundraising requirements (60.0%). In responding to the question regarding beneficial transplant-related education resources, the most frequently cited materials were those that addressed financial barriers to kidney transplantation.
Finally, the researchers aimed to identify whether variation in the implementation of the RADIANT intervention and its components influenced study outcomes (change in facility-level transplant referrals, stratified by patient race, at the conclusion of the 2014 intervention year). Results of the analysis demonstrated that the increase in the proportion of patients referred across Georgia dialysis facilities following the intervention year was not significantly affected by implementation fidelity.
The researchers cited some limitations to the evaluation process, including the use of staff-reported data that may have resulted in social desirability bias due to over-reporting of adherence to requirements of the intervention, which may then have resulted in overestimation of the fidelity measures. The process also limited survey responses to one staff response per facility, and the researchers were unable to obtain patient-level data on the receipt or helpfulness of patient-level intervention components. Finally, because the RADIANT intervention is multicomponent, it was not possible to determine which components were most effective.
In conclusion, the authors said, “The RADIANT multicomponent intervention was implemented with high fidelity, demonstrated potential for sustainability among Georgia dialysis facilities, and may be feasible for dissemination to facilities across ESRD Networks outside of Georgia. Further modification efforts should include adopting more intervention components aimed to address financial concerns regarding kidney transplantation, amending intervention components that are perceived by dialysis facilities as time-intensive or logistically challenging, and promoting patient- and facility-level components that staff perceive as both helpful and sustainable.”
- Researchers conducted a process evaluation to examine implementation of the RADIANT intervention administered in dialysis facilities in Georgia in 2014. The intervention was an education and quality improvement program aimed at increasing referral for kidney transplantation among selected Georgia dialysis facilities.
- The program included nine required intervention activities and five optional intervention activities. Process evaluation measures were fidelity, sustainability, reach, and context.
- The program was implemented with high fidelity, had potential for sustainability among dialysis facilities in Georgia, and may be feasible for dissemination across ESRD Networks outside of Georgia.