Tanjala S. Purnell

Understanding and Overcoming Barriers to Living Kidney Donation Among Racial and Ethnic Minorities in the United States

In the United States, racial-ethnic minorities experience disproportionately high rates of ESRD, but they are substantially less likely to receive living donor kidney transplants (LDKT) compared with their majority counterparts. Minorities may encounter barriers to LDKT at several steps along the path to receiving it, including consideration, pursuit, completion of LDKT, and the post-LDKT experience. These barriers operate at different levels related to potential recipients and donors, health care providers, health system structures, and communities. In this review, we present a conceptual framework describing various barriers that minorities face along the path to receiving LDKT. We also highlight promising recent and current initiatives to address these barriers, as well as gaps in initiatives, which may guide future interventions to reduce racial-ethnic disparities in LDKT.

Patient Preferences for Noninsulin Diabetes Medications: A Systematic Review

OBJECTIVE An evidence-based synthesis of patient preferences for management of hyperglycemia is needed. Our objective was to systematically review patient preferences for noninsulin diabetes medications in adults with type 2 diabetes. RESEARCH DESIGN AND METHODS We searched the PubMed, Embase, CINAHL, and EconLit databases for articles published on or before 23 January 2013. We included English-language studies of adult patients with type 2 diabetes that assessed patient preferences for diabetes medication treatment. Titles, abstracts, and articles were reviewed by at least two independent reviewers. Study data and quality were abstracted with standard protocols. RESULTS Of 2,811 titles identified in our original search, 10 articles met inclusion criteria for the systematic review. Studies were conducted from 2007 to 2012 among diverse patient populations in the U.S., Sweden, Denmark, and the U.K. Methods used to assess patient preferences included discrete choice experiments (e.g., conjoint analysis), time tradeoff exercises, standard gamble, and patient surveys. Key attributes of diabetes medication associated with patient preferences included treatment benefits (e.g., glycemic control and weight loss/control), treatment burden (e.g., administration, frequency, and cost), and side effects (e.g., weight gain, gastrointestinal effects, and hypoglycemia). CONCLUSIONS Various clinical and quality of life–related factors influence patient preferences for noninsulin diabetes medications. Treatment efficacy with regard to glycemic control and weight loss/control and the risk of treatment-related hypoglycemia and gastrointestinal effects are reported to be important drivers of patient treatment selections. Future work is needed to identify practical methods for incorporating patient preferences into treatment decision making and patient-centered care.

Reducing racial and ethnic disparities in hypertension prevention and control: what will it take to translate research into practice and policy?

INTRODUCTION Despite available, effective therapies, racial and ethnic disparities in care and outcomes of hypertension persist. Several interventions have been tested to reduce disparities; however, their translation into practice and policy is hampered by knowledge gaps and limited collaboration among stakeholders. METHODS We characterized factors influencing disparities in blood pressure (BP) control by levels of an ecological model. We then conducted a literature search using PubMed, Scopus, and CINAHL databases to identify interventions targeted toward reducing disparities in BP control, categorized them by the levels of the model at which they were primarily targeted, and summarized the evidence regarding their effectiveness. RESULTS We identified 39 interventions and several state and national policy initiatives targeted toward reducing racial and ethnic disparities in BP control, 5 of which are ongoing. Most had patient populations that were majority African-American. Of completed interventions, 27 demonstrated some improvement in BP control or related process measures, and 7 did not; of the 6 studies examining disparities, 3 reduced, 2 increased, and 1 had no effect on disparities. CONCLUSIONS Several effective interventions exist to improve BP in racial and ethnic minorities; however, evidence that they reduce disparities is limited, and many groups are understudied. To strengthen the evidence and translate it into practice and policy, we recommend rigorous evaluation of pragmatic, sustainable, multilevel interventions; institutional support for training implementation researchers and creating broad partnerships among payers, patients, providers, researchers, policymakers, and community-based organizations; and balance and alignment in the priorities and incentives of each stakeholder group.

Racial differences in determinants of live donor kidney transplantation in the United States.

Few studies have compared determinants of live donor kidney transplantation (LDKT) across all major US racial‐ethnic groups. We compared determinants of racial‐ethnic differences in LDKT among 208 736 patients who initiated treatment for end‐stage kidney disease during 2005–2008. We performed proportional hazards and bootstrap analyses to estimate differences in LDKT attributable to sociodemographic and clinical factors. Mean LDKT rates were lowest among blacks (1.19 per 100 person‐years [95% CI: 1.12–1.26]), American Indians/Alaska Natives‐AI/ANs (1.40 [1.06–1.84]) and Pacific Islanders (1.10 [0.78–1.84]), intermediate among Hispanics (2.53 [2.39–2.67]) and Asians (3.89 [3.51–4.32]), and highest among whites (6.46 [6.31–6.61]). Compared with whites, the largest proportion of the disparity among blacks (20%) and AI/ANs (29%) was attributed to measures of predialysis care, while the largest proportion among Hispanics (14%) was attributed to health insurance coverage. Contextual poverty accounted for 16%, 4%, 18%, and 6% of the disparity among blacks, Hispanics, AI/ANs and Pacific Islanders but none of the disparity among Asians. In the United States, significant disparities in rates of LDKT persist, but determinants of these disparities vary by race‐ethnicity. Efforts to expand preESKD insurance coverage, to improve access to high‐quality predialysis care and to overcome socioeconomic barriers are important targets for addressing disparities in LDKT.

Achieving Health Equity: Closing The Gaps In Health Care Disparities, Interventions, And Research

In the United States, racial/ethnic minority, rural, and low-income populations continue to experience suboptimal access to and quality of health care despite decades of recognition of health disparities and policy mandates to eliminate them. Many health care interventions that were designed to achieve health equity fall short because of gaps in knowledge and translation. We discuss these gaps and highlight innovative interventions that help address them, focusing on cardiovascular disease and cancer. We also provide recommendations for advancing the field of health equity and informing the implementation and evaluation of policies that target health disparities through improved access to care and quality of care.

CLINICIAN PERCEPTIONS OF AN ELECTRONIC MEDICAL RECORD DURING THE FIRST YEAR OF IMPLEMENTATON IN EMERGENCY SERVICES

Objectives: The objectives of this study were to measure clinician perceptions of the recently implemented electronic medical record (EMR) system in a pediatric emergency department and off-site urgent care centers and to determine how user perceptions changed over time. Methods: Physicians and nurses from the emergency department/urgent care center were recruited to complete an online survey at 3 points in time: 30 to 89 days (wave 1), 90 to 179 days (wave 2), and 180 to 270 days after implementation (wave 3). Potential predictors of initial satisfaction studied included effort expectancy, performance expectancy, social support, and facilitating conditions, along with user demographics and general attitudes toward technology. Bivariate relationships with satisfaction were assessed using the Wilcoxon rank sum test and correlation analysis. A final multivariate linear regression model was calculated. Change in satisfaction over time was tested using a Wilcoxon signed rank test. Results: A total of 71 clinicians completed the surveys. Initial satisfaction was strongly associated with perceptions of training and support (facilitating conditions) and with perceived usefulness (performance expectancy). Satisfaction was not associated with user sex, age, or role (physician vs nurse). No significant change was found in any satisfaction measure at wave 2 or 3; however, satisfaction with functionality trended higher and satisfaction with reliability trended lower over the course of use. Conclusions: Satisfaction with an EMR at its launch generally persisted through the first year of use. Implementation plans must maximize the likelihood of achieving positive early impressions of training, support, and performance to engender high user satisfaction with the EMR.

The providing resources to enhance African American patients' readiness to make decisions about kidney disease (PREPARED) study: protocol of a randomized controlled trial

BackgroundLiving related kidney transplantation (LRT) is underutilized, particularly among African Americans. The effectiveness of informational and financial interventions to enhance informed decision-making among African Americans with end stage renal disease (ESRD) and improve rates of LRT is unknown.Methods/designWe report the protocol of the Providing Resources to Enhance African American Patients’ Readiness to Make Decisions about Kidney Disease (PREPARED) Study, a two-phase study utilizing qualitative and quantitative research methods to design and test the effectiveness of informational (focused on shared decision-making) and financial interventions to overcome barriers to pursuit of LRT among African American patients and their families. Study Phase I involved the evidence-based development of informational materials as well as a financial intervention to enhance African American patients’ and families’ proficiency in shared decision-making regarding LRT. In Study Phase 2, we are currently conducting a randomized controlled trial in which patients with new-onset ESRD receive 1) usual dialysis care by their nephrologists, 2) the informational intervention (educational video and handbook), or 3) the informational intervention in addition to the option of participating in a live kidney donor financial assistance program. The primary outcome of the randomized controlled trial will include patients’ self-reported rates of consideration of LRT (including family discussions of LRT, patient-physician discussions of LRT, and identification of a LRT donor).DiscussionResults from the PREPARED study will provide needed evidence on ways to enhance the decision to pursue LRT among African American patients with ESRD.Trial registrationClinicalTrials.gov NCT01439516

Measuring and Explaining Racial and Ethnic Differences in Willingness to Donate Live Kidneys in the United States

Reasons for US racial–ethnic minority ESRD patients’ reported difficulties identifying live kidney donors are poorly understood.

A community-engaged cardiovascular health disparities research training curriculum: Implementation and preliminary outcomes

To overcome cardiovascular disease (CVD) disparities impacting high-risk populations, it is critical to train researchers and leaders in conducting community-engaged CVD disparities research. The authors summarize the key elements, implementation, and preliminary outcomes of the CVD Disparities Fellowship and Summer Internship Programs at the Johns Hopkins University Schools of Medicine, Nursing, and Bloomberg School of Public Health. In 2010, program faculty and coordinators established a transdisciplinary CVD disparities training and career development fellowship program for scientific investigators who desire to conduct community-engaged clinical and translational disparities research. The program was developed to enhance mentorship support and research training for faculty, postdoctoral fellows, and predoctoral students interested in conducting CVD disparities research. A CVD Disparities Summer Internship Program for undergraduate and preprofessional students was also created to provide a broad experience in public health and health disparities in Baltimore, Maryland, with a focus on CVD. Since 2010, 39 predoctoral, postdoctoral, and faculty fellows have completed the program. Participating fellows have published disparities-related research and given presentations both nationally and internationally. Five research grant awards have been received by faculty fellows. Eight undergraduates, one postbaccalaureate, and two medical professional students representing seven universities have participated in the summer undergraduate internship. Over half of the undergraduate students are applying to or have been accepted into medical or graduate school. The tailored CVD health disparities training curriculum has been successful at equipping varying levels of trainees (from undergraduate students to faculty) with clinical research and public health expertise to conducting community-engaged CVD disparities research.

Reduced Racial Disparity in Kidney Transplant Outcomes in the United States from 1990 to 2012

Earlier studies reported inferior outcomes among black compared with white kidney transplant (KT) recipients. We examined whether this disparity improved in recent decades. Using the Scientific Registry of Transplant Recipients and Cox regression models, we compared all-cause graft loss among 63,910 black and 145,482 white adults who received a first-time live donor KT (LDKT) or deceased donor KT (DDKT) in 1990-2012. Over this period, 5-year graft loss after DDKT improved from 51.4% to 30.6% for blacks and from 37.3% to 25.0% for whites; 5-year graft loss after LDKT improved from 37.4% to 22.2% for blacks and from 20.8% to 13.9% for whites. Among DDKT recipients in the earliest cohort, blacks were 39% more likely than whites to experience 5-year graft loss (adjusted hazard ratio [aHR], 1.39; 95% confidence interval [95% CI], 1.32 to 1.47; P<0.001), but this disparity narrowed in the most recent cohort (aHR, 1.10; 95% CI, 1.03 to 1.18; P=0.01). Among LDKT recipients in the earliest cohort, blacks were 53% more likely than whites to experience 5-year graft loss (aHR, 1.53; 95% CI, 1.27 to 1.83; P<0.001), but this disparity also narrowed in the most recent cohort (aHR, 1.37; 95% CI, 1.17 to 1.61; P<0.001). Analyses revealed no statistically significant differences in 1-year or 3-year graft loss after LDKT or DDKT in the most recent cohorts. Our findings of reduced disparities over the last 22 years driven by more markedly improved outcomes for blacks may encourage nephrologists and patients to aggressively promote access to transplantation in the black community.