“Concierge” screening for kidney transplant candidates leads to better outcomes, UNM researcher finds

(Press-News.org) Patients hoping for a kidney transplant must first undergo a battery of medical tests to determine whether they are suitable candidates for the procedure and healthy enough to take post-transplant immunosuppressant drugs to prevent organ rejection.

In most transplant centers, the burden falls on the patient to arrange tests like cardiac catheterization, CT scans, mammograms or colonoscopies, which can year or more to complete, meaning some people never complete the process, while others get sicker or die.

But a new study published in JAMA Internal Medicine led by a University of New Mexico Health Sciences researcher demonstrates that a “concierge” approach called the Kidney Transplant Fast Track (KTFT), in which the testing is coordinated and often performed onsite by the transplant center, enables more people to receive transplants and erases troubling racial and ethnic  disparities.

Larissa Myaskovsky, PhD, a professor in the UNM Department of Internal Medicine and director of the Center for Healthcare Equity in Kidney Disease, led a nonrandomized clinical trial by researchers from UNM and the University of Pittsburgh Medical Center (UPMC) that compared the two screening methods.

Myaskovsky, who was at UPMC before joining the UNM faculty in 2017, said the study originated in research she was conducting on UPMC kidney transplant patients in the early 2000s. She also worked at the VA Pittsburgh Healthcare System, where all kidney transplants are coordinated by the center.

“Underlying a lot of my thinking when I planned this intervention is, ‘Why are we putting the burden on the ill patients and their family members to change their behavior?’” she said. “Can we do something as an organization to change our behavior and address the needs of the patient?”

Myaskovsky met with clinicians, surgical leadership and hospital administration to discuss the Kidney Transplant Fast Track. Her plan was to randomly assign some patients to the usual regimen of testing and others to the KTFT and then compare their outcomes.

“Apparently, I was so convincing to hospital administration about the fast-track intervention that they decided, ‘No, we’re just going to change evaluation in that way,’” she said. Her new research strategy entailed comparing a control group of 1,152 UPMC patients who were evaluated for transplants prior to 2013, when the new KTFT procedure was implemented, with 1,118 participants who were screened from that point forward.

The study found that the KTFT patients were more likely to be placed on the active waitlist for kidney transplant over a seven-year follow-up period than those in the historical control group. And among patients on the active waitlist, those in the KTFT group were more likely to receive a kidney transplant than those in the historical control group.

The study also found that a previous disparity between African American and White patients in the historical control group disappeared when the KTFT system was implemented. “There was not that difference between African American and Whites in the fast-track group,” Myaskovsky said.

While it might seem like a no-brainer to have a transplant center supervise and consolidate testing at one location, it requires an investment of personnel to make that happen, she said. The payoff is that the new approach resulted in greater revenue for the transplant center.

“Not only are you coordinating the care and getting tests done, but now it's all done in-house,” Myaskovsky said. “So instead of relying on third parties, and those third parties getting that insurance coverage, it would all now come to UPMC.  Of course, the finance and administrative leadership was thrilled for that, because that gave them a value for investing the FTEs and coordinating the care.”

In addition to getting more patients in the pipeline to receive a transplant, the fast-track approach also provides greater clarity for patients who might be ineligible for the surgery.

“Frankly, the ambiguity of not knowing their clinical state may actually be more  psychologically more difficult for patients than what might come from being rejected for transplant,” she said. “Because then at least they can proceed with adjusting to that new reality of having to stay on dialysis, and they're not left waiting and wondering what their results are and whether they're waitlisted or not.”

Most of the patients at UPMC had insurance, Myaskovsky noted. She and her UNM colleagues are running a federally funded study to see whether similar benefits might accrue by implementing a new screening protocol at New Mexico’s only public safety-net hospital, which serves many uninsured patients. In this new study, one group of patients is randomly assigned to the KTFT process, while the others interact with “peer navigators,” people who have themselves undergone kidney transplants and are familiar with the process.

“They serve as counselors or peer mentors,” she said.  “We recruited former transplant recipients who got their transplant as UNM. They got all the Institutional Review Board-required training needed to be part of the research team. We're comparing not only the intervention – which approach works best – but also which approach works best for which kind of patients.”

Myaskovsky and her colleagues are sharing the protocol for implementing the KTFT approach in hopes that it will be adopted by other kidney transplant centers. “As a researcher, my focus might be on the specific variables, but I’m thinking about how we change the health care system to meet the needs of our patients.”

Additional information on the KTFT protocol may be found here and here.

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