American Journal of Kidney Diseases
Volume 51, Issue 4 , Pages 542-544, April 2008

The Home Is Where the Donor Might Be

  • Bryan N. Becker, MD

      Affiliations

    • Corresponding Author InformationAddress correspondence to Bryan N. Becker, MD, J5/223 CSC, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792.

University of Wisconsin, Madison, Wisconsin

Article Outline

 

Related article, p. 663

“All politics is local.”

This phrase, attributed to Thomas P. (Tip) O’Neill, can be interpreted in many ways, but in the end, suggests that to have an impact, you have to be close to home. When it comes to health care, being close to home traditionally meant home remedies or home visits, popularized by the house calls of old. These focused on immediate health concerns or conditions, and even today, home health care most frequently addresses acute visits or monitoring disease states. Therefore, what if we used the home as an additional site for health care education and moved its subject matter to a cutting-edge feature of medicine, such as kidney transplantation?

This is exactly what Rodrigue et al1 decided to do in constructing their study examining home-based education and its potential impact on encouraging living donation. They developed an initial study2 that asked whether a home-based educational program could alter awareness, interest, and, ultimately, rates of living donation for individuals who had undergone kidney transplantation evaluation. It encompassed 132 subjects, nearly half African American, who were randomly assigned to a clinic-based transplantation education program or a clinic plus standardized home-based transplantation education program. The clinic-based education program consisted of the transplant surgeon or nephrologists discussing living donation with the patient, along with the transplant coordinator and physician assistant, and a same-day 60-minute group visit with other transplantation patients. The home-based education program included the clinic education plus a home visit from 2 transplant health educators, when feasible. This encompassed another 60- to 90-minute interactive visit with the patient, family, and friends, along with a 15-minute videotape and an opportunity to review additional written materials. The investigators planned a secondary analysis of the primary study to evaluate the program separately in subgroups of African Americans and in whites, reported in this issue of the AJKD.1

At 12 months, it was apparent that more individuals in the clinic plus home-based education intervention had made living donor inquiries, had 1 or more living donors evaluated, and ended up with more living donor kidney transplantations. The effect appeared to be greater in the African American subgroup than in the white subgroup, at least for inquiries (clinic + home, 24/31 African American patients and 28/32 white patients; clinic alone, 15/29 African American patients and 29/40 white patients) and evaluations (clinic + home 15/31 African American patients and 23/32 white patients; clinic alone, 5/29 African American patients and 19/40 white patients). The investigators attributed this to the home visit and the opportunity it provided to engage family members, friends, and significant others in an appropriate and fair discussion about the transplantation process. This is especially important because prior studies showed that rates of transplantation were lower in African Americans than in whites, as were donor inquiries and evaluations.3, 4, 5

Results of this study are tremendously encouraging. First and foremost, this type of program represents another possible strategy to increase living donation. With the increasing disparity between the number of individuals waiting for a kidney transplant and the availability of deceased donor organs,6 this type of study is an important piece of evidence in developing a new approach to improving rates of living donation. This becomes all the more significant because rates of living donor kidney transplantation have leveled off during the last several years.7 Second, this study provides new tactics that we can possibly incorporate into practice to overcome observed disparities in access to transplantation by race.8, 9, 10 Third, such a program, as the investigators noted, should build more trust in the transplantation center in general, a key feature for any patient who ultimately receives a transplant given the increasingly recognized importance of posttransplantation medical care and follow-up.11 Last, any type of intervention in health care should be held to various standards. The principles suggested in 2001 by the Institute of Medicine in their report, “Crossing the Quality Chasm: A New Health System for the 21st Century,”12 remain as true today as they were then. This study highlights a new way to provide a component of health care that certainly appears to be effective, equitable, and patient centered, all things that we should strive to achieve in any context of kidney health care.

However, the success of this idea begets a number of other questions. The study construct itself relied on the natural variation in exposure to transplantation education at the transplantation center. It would have been more balanced and likely have decreased the reinforcement bias by having an additional educational intervention of some kind for the clinic-based education. This could have ranged from a telephone call or mailing the home-based visit information to the patient to even a cellular telephone contact of some kind. It would have been helpful to contact the patient outside the clinic in some way.

The importance of this piece enhancing the validity of the study construct cannot be overemphasized.

The team composition itself obviously was an important consideration, as was the construct of the home visit materials and curriculum. Cultural awareness suggests that such programs would have to be individualized for various racial and ethnic groups. Identifying the right personnel and providing adequate cultural education regarding values and perception of health can be difficult,13 and doing so for multiple racial and ethnic groups brings a level of complexity to this that may stress many transplantation centers.

Data collection focused on the living donation process. Unfortunately, there were no follow-up data relating to attitudes, including perception of coercion, from individuals who made inquiries or even underwent evaluation or living donation. This is an important consideration as we consider all the motives that inform living donation.

And yes, there is a cost. The program itself was time and personnel intensive. Funding such a program could be complex. With the present conditions of coverage already holding dialysis facilities and transplantation centers accountable for access to transplantation and education, this becomes an effort that would likely fall on the financial shoulders of the transplantation center.

Depending on financial status, such a program might be viewed with great scrutiny, especially because it would take personnel out of the center and away from their other regular work duties. Paradoxically, large transplantation programs with strong living donation components probably already have an infrastructure that can enhance the clinic-based visit to such an extent that they can continue to achieve excellent rates of living donation. Smaller programs that might benefit from both clinic- and home-based education programs may be those that have less financial freedom to overtly support such a program.

The house call remains one of the iconic features of the caring physician in the health care lore of our country. This study by Rodrigue et al1, 2 has taken the house call into a new mode. The short-term impact of this group’s work should spur greater efforts in developing infrastructure and materials for home-based education programs, along with standardized curriculum that can meet the special needs of various racial and ethnic groups. Individuals interested in such work also should focus on how best to communicate with patients about such subjects, including type of communication, language, other participants in the conversation, and even frequency and modality of follow-up communication. However, in the end, by taking high-technology medicine (transplantation) to the level of the house call, but reconfiguring it to provide education, Rodrigue et al1, 2 offer an intriguing new model for how to understand our patients better. If we can make that a standard of care in some way, we will be honoring the words of the Irish poet Thomas Moore (1779-1852), who wrote, “The ordinary acts we practice every day at home are of more importance to the soul than their simplicity might suggest.”

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Acknowledgements 

Support: None.

Financial Disclosure: None.

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References 

  1. Rodrigue JR, Cornell DL, Kaplan B, Howard RJ. A randomized trial of a home-based educational approach to increase live donor kidney transplantation: Effects in blacks and whites. Am J Kidney Dis. 2008;51:663–670
  2. Rodrigue JR, Cornell DL, Lin JK, Kaplan B, Howard RJ. Increasing live donor kidney transplantation: A randomized controlled trial of a home-based educational intervention. Am J Transplant. 2007;7:394–401
  3. Lunsford SL, Shilling LM, Chavin KD, et al. Racial differences in the living kidney donation experience and implications for education. Prog Transplant. 2007;17:234–240
  4. Lunsford SL, Simpson KS, Chavin KD, et al. Racial disparities in living kidney donation: Is there a lack of willing donors or an excess of medically unsuitable candidates?. Transplantation. 2006;82:876–881
  5. Navaneethan SD, Singh S. A systematic review of barriers in access to renal transplantation among African Americans in the United States. Clin Transplant. 2006;20:769–775
  6. 2006 OPTN/SRTR Annual Report 1996-2005. HHS/HRSA/HSB/DOT, Tables I-1 and I-2.
  7. Scientific Registry of Transplant Recipients: 2006 Annual Data Report. Chapter IV, Table IV-2 2007;
  8. Ayanian JZ, Cleary PD, Weissman JS, Epstein AM. The effect of patients’ preferences on racial differences in access to renal transplantation. N Engl J Med. 1999;341:1661–1669
  9. Epstein AM, Ayanian JZ, Keogh JH, et al. Racial disparities in access to renal transplantation—Clinically appropriate or due to underuse or overuse?. N Engl J Med. 2000;343:1532;1537-1544
  10. Stolzmann KL, Bautista LE, Gangnon RE, McElroy JA, Becker BN, Remington PL. Trends in kidney transplantation rates and disparities. J Natl Med Assoc. 2007;99:923–932
  11. Djamali A, Samaniego M, Muth B, et al. Medical care of kidney transplant recipients after the first posttransplant year. Clin J Am Soc Nephrol. 2006;1:623–640
  12. Committee on Quality of Healthcare in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: Institute of Medicine; 2001;
  13. Fadiman A. The Spirit Catches You and You Fall Down. New York, NY: Farrar, Straus, & Giroux; 1997;

PII: S0272-6386(08)00042-5

doi:10.1053/j.ajkd.2008.01.005

Refers to article:

  • A Randomized Trial of a Home-Based Educational Approach to Increase Live Donor Kidney Transplantation: Effects in Blacks and Whites , 21 February 2008

    James R. Rodrigue, Danielle L. Cornell, Bruce Kaplan, Richard J. Howard
    American Journal of Kidney Diseases April 2008 (Vol. 51, Issue 4, Pages 663-670)

American Journal of Kidney Diseases
Volume 51, Issue 4 , Pages 542-544, April 2008

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