The ASCENT Intervention to Improve Access and Reduce Racial Inequalities in Kidney Waitlisting: A Randomized, Effectiveness-Implementation Trial

Abstract

Background: The U.S. kidney allocation system (KAS) changed in 2014, but dialysis facility staff (including nephrologists, social workers, nurse managers, and facility administrators) had low awareness of how this policy change could impact their patients’ access to transplant. We assessed the effectiveness of a multi-component and multi-level educational and outreach intervention targeting U.S. dialysis facilities with low waitlisting, with a goal of increasing waitlisting and reducing Black vs. White racial disparities in waitlisting.

Methods: The ASCENT study was a cluster-randomized, pragmatic, multi-level, effectiveness-implementation trial including 655 U.S. dialysis facilities with low waitlisting, randomized to receive either the ASCENT intervention (a performance feedback report, a webinar, and staff and patient educational videos) or an educational brochure. Absolute and relative differences in co-primary outcomes (1-year waitlisting and racial differences in waitlisting) were reported among incident and prevalent patients.

Results: Among 56,332 prevalent patients, 1-year waitlisting decreased for patients in control facilities (2.72% to 2.56%), and remained the same for patients in intervention facilities (2.68% to 2.75%). However, the proportion of prevalent Black patients’ waitlisted in the ASCENT interventions increased from baseline to 1-year (2.52% to 2.78%) while remaining the same for White patients in the ASCENT intervention facilities (2.66% to 2.69%). Among incident patients in ASCENT facilities, 1-year waitlisting increased among Black patients (from 0.87% to 1.07%) but declined among White patients (1.54% to 1.27%). Significant racial disparities in waitlisting were observed at baseline, with incident Black patients in ASCENT facilities less likely to waitlist compared to White patients (aOR: 0.56; 95% CI: 0.35, 0.92), but one year following the intervention this racial disparity was attenuated (aOR: 0.84; 95% CI: 0.49-1.42).

Conclusions: The ASCENT intervention may have a small impact on extending the reach of the new KAS policy by attenuating racial disparities in waitlisting among a population of U.S. dialysis facilities with low waitlisting.