Main educators
General educators are defined as self-selected “direct” educator AND who educated at least 1 English/Spanish Speaking patient.
ET HRSA4-5 Analysis
Yujie Cui
2019-11-06
Introduction
Participating Dialysis Centers
In a national quality improvement initiative, dialysis centers from ESRD Networks throughout the United States were invited to participate in a one day Explore Transplant (ET) educational training. Only dialysis centers that participated in the ET trainings are considered for this study. The inclusion criterion for dialysis centers is to have sent a staff representative to one of 78 ET trainings over a four year period between 3/20/2011 and 3/18/2015.
Representatives from 1989 unique dialysis centers attended trainings, though centers were excluded due to only providing acute dialysis (19 centers), serving only pediatric patients (17 centers), refusal to participate in the study (23 centers), and not responding to a survey given during the trainings (38 centers). Further, X centers did not initiate dialysis with at least 1 new patient during wait-listing and transplant rate follow-up periods (see below). This resulted in a sample of X unique dialysis centers.
Patient Selection
Patients from participating dialysis center will be selected to calculate transplant wait-listing and transplantation rates in two cohorts: a pre-ET cohort and a post-ET cohort. For the pre-ET cohort, incident dialysis patients who initialized dialysis treatment between 21 and 12 months prior to their center’s ET training will be sampled. For the post-ET cohort, incident dialysis patients who initialized dialysis between 3 months before the ET training date and 6 months after will be sampled. Patients in the post-ET cohort who started dialysis during this time are most likely to have been exposed ET from their dialysis staff, while patients sampled for the pre-ET cohort would not have any exposure to ET.
Calculation of Wait-listing and Transplant Rates
Annualized 12 month wait-listing and transplant rates for each dialysis center will be calculated for before and after the ET trainings. Each rate will be defined as the number of patients who have the event of interest (wait-list or receive a transplant) divided by the total days patients are at risk during the follow-up period, then multiplied by 365.25. Patients will be censored at death. To calculate the pre-ET 12-month annualized rates, incident dialysis patients between 21 and 12 months prior to the ET training will be followed for 12 months. The follow-up for the last patients included in this cohort would end at the ET training date. For the post-ET 12 month rates, incident dialysis patients between 3 months prior to the ET training date and 6 months after the training date will be followed for 12 months. The follow-up for the last patients in this cohort will end 18 months after the ET date. This gives an equal sample period (9 months) and equal follow-up period (12 months) for both the pre- and post-ET rates. The figure below shows the sampling and follow-up of patients for the wait-listing and transplant rates.
Paper 1 aims
HRSA 4&5 Combined Analysis Plan
Aims - Paper 1
1. Characteristics of dialysis center providers educating about transplant including level of preparedness (slides exist) [is this its own paper?]
2. Did trainings increase dialysis providers’ knowledge about deceased and living donor transplantation?
3. Did trainings motivate dialysis providers to use Explore Transplant with their own Spanish- and English-speaking patients in the next six months?
Paper 2 aims
Six months after the trainings, to assess dialysis providers’ use of and success in educating 4,000 dialysis patients about deceased and living donation using Explore Transplant. We will conduct process and outcome evaluations to understand:
1. How specific Explore Transplant educational resources are being used in individual dialysis centers. 2. Whether the majority of providers are educating an average of 5 patients using Explore Transplant within their centers within six months. 3. How specific patient, provider and dialysis center factors facilitate or serve as barriers to educating English- and Spanish-speaking patients using Explore Transplant.
Statistical methods
- The proportion of dialysis centers sending at least one dialysis educator to the in-person or eLearning trainings will then be assessed. The total number of dialysis providers trained and the average number of providers trained per center will be calculated using descriptive statistics including proportions and means.
- We will assess whether providers’ deceased and living donation knowledge significantly increased following the trainings using paired t-tests or McNemar tests.
- The proportion of providers willing to take each action, including educating 5 patients, and the total number of patients planning to be educated will be calculated to assess the scope of the planned education to occur in the next six months by providers across all Networks.
- Difference-In-Difference analysis will be used to compare WL and LDKT rates pre and post Explore Transplant education.
Data loading
The ET dataset was merged from the pre and post dataset from USRDS and has 1700 patients in each arm with about 62 variables. One center ID in this dataset was not found in the WL paper (532307) needs further attention.
## Min. 1st Qu. Median Mean 3rd Qu. Max. NA's
## 0.0000 1.0000 1.0000 0.8128 1.0000 1.0000 27## Min. 1st Qu. Median Mean 3rd Qu. Max. NA's
## 0.00 4.00 5.00 10.45 10.00 100.00 1398## Min. 1st Qu. Median Mean 3rd Qu. Max. NA's
## 0.000 0.000 1.000 2.786 2.000 50.000 1403Number of centers vs. number of unique attendees
- 1495 UNIQUE ids for educators
- We have 1976 unique centers/dialysis providers.
Descriptive Analysis
Table 1. Characteristics of providers
| rn | Overall |
|---|---|
| n | 1500 |
| age (mean (sd)) | 45.63 (11.40) |
| gender2 = Female (%) | 1009 (68.2) |
| race8 (%) | |
| White | 981 (66.9) |
| African American or Black | 205 (14.0) |
| Hispanic or Latino | 91 ( 6.2) |
| American Indian or Alaskan Native | 14 ( 1.0) |
| Asian | 151 (10.3) |
| Native Hawaiian or other Pacifc Islander | 3 ( 0.2) |
| Multiracial | 14 ( 1.0) |
| Other | 8 ( 0.5) |
| jobs (%) | |
| Medical Director/Physician | 1 ( 0.1) |
| Nurse Manager/Facility Administrator | 138 ( 9.4) |
| Nurse (RN/LPN/MSN/APN) | 261 (17.7) |
| Dietician | 103 ( 7.0) |
| Social Worker (MSW) | 743 (50.4) |
| Dialysis Technician | 170 (11.5) |
| Other | 58 ( 3.9) |
| workpattot (mean (sd)) | 10.56 (8.92) |
| spanish_yn (%) | |
| No | 1361 (92.8) |
| Yes | 104 ( 7.1) |
| Don’t know | 2 ( 0.1) |
| strong_rel (%) | |
| No | 784 (54.6) |
| Yes | 622 (43.3) |
| Don’t know | 29 ( 2.0) |
| totknowpre (mean (sd)) | 5.21 (2.09) |
| op_priord = Yes (%) | 1329 (91.3) |
| op_knowd = Yes (%) | 834 (57.5) |
| op_abilityd = Yes (%) | 759 (52.7) |
| op_txmatd = Yes (%) | 637 (44.2) |
Formal education at providers’ centers?
Table 2. Educational practises
- Is transplant information provided at least once to all transplant candidates, whether they have expressed interest in transplant or not (ctr1info1x:ctr3info3x);
- Is transplant information provided every year to all transplant candidates, whether they have expressed interest in transplant or no (CTR1INFOYR:CTR3INFOYR);
- Have a designated transplant educator or team of educators at their dialysis centers (CTR1EDUC: CTR3EDUC);
## [1] 28## df0.uniq$ctr1info1x n percent valid_percent
## 0 33 0.02207358 0.02327221
## 1 1337 0.89431438 0.94287729
## 2 48 0.03210702 0.03385049
## NA 77 0.05150502 NA## df0.uniq$ctr2info1x n percent valid_percent
## 0 10 0.006688963 0.01533742
## 1 599 0.400668896 0.91871166
## 2 43 0.028762542 0.06595092
## NA 843 0.563879599 NA## df0.uniq$ctr3info1x n percent valid_percent
## 0 1 0.0006688963 0.003875969
## 1 242 0.1618729097 0.937984496
## 2 15 0.0100334448 0.058139535
## NA 1237 0.8274247492 NA## value n percent valid_percent
## 0 44 0.009810479 0.01890034
## 1 2178 0.485618729 0.93556701
## 2 106 0.023634337 0.04553265
## NA 2157 0.480936455 NA## value n percent
## 0 46 0.01965812
## 1 2188 0.93504274
## 2 106 0.04529915## value n percent
## 0 204 0.09066667
## 1 1853 0.82355556
## 2 193 0.08577778## value n percent
## 0 750 0.32202662
## 1 1385 0.59467583
## 2 194 0.08329755## value n percent
## 0 1176 0.51130435
## 1 909 0.39521739
## 2 215 0.09347826Preparedness of providers
Limit analysis to main educators?
Efficacy overall
- priority
- knowledgable
- ability
- materials
## $op_priord
## x n percent valid_percent
## No 127 0.08466667 0.08722527
## Yes 1329 0.88600000 0.91277473
## <NA> 44 0.02933333 NA
##
## $op_knowd
## x n percent valid_percent
## No 616 0.41066667 0.4248276
## Yes 834 0.55600000 0.5751724
## <NA> 50 0.03333333 NA
##
## $op_abilityd
## x n percent valid_percent
## No 681 0.454 0.4729167
## Yes 759 0.506 0.5270833
## <NA> 60 0.040 NA
##
## $op_txmatd
## x n percent valid_percent
## No 805 0.53666667 0.5582524
## Yes 637 0.42466667 0.4417476
## <NA> 58 0.03866667 NATransplant knowledge items
Mean = 5.34, SD = 2.07, Median = 5, range 0-12.
| n | mean | sd | IQR | p00 | p50 | p100 |
|---|---|---|---|---|---|---|
| 1478 | 5.2 | 2.1 | 3 | 0 | 5 | 12 |
How did the providers do on individual knowledge items overall?
## var n(%)
## 1 otyped 876 (58.4)
## 2 ldbpd 485 (32.3)
## 3 lvlongerd 1188 (79.2)
## 4 pcttxfund 688 (45.9)
## 5 waittimed 808 (53.9)
## 6 surgdied 647 (43.1)
## 7 ldtxlastd 312 (20.8)
## 8 ddtxlastd 336 (22.4)
## 9 govtpayd 835 (55.7)
## 10 ldexpd 632 (42.1)
## 11 normactd 512 (34.1)
## 12 dialfunctd 383 (25.5)Table 3. Common Educational practices for conducting transplant education
Most common education strategies reported by educators were learning more about transplant (80% ), recommended being evaluated for transplant (80% ), referred patients to educational program at a transplant/kidney organization (51% ), provided handouts about transplant (50% ) and distributed transplant center phone numbers (44% ). Only 26% of the educators said to have detailed discussion about advantages/risks of living and deceased donation (Table 3).
Table 3. Educational practices among main educators (N=1495) | |
label | N (%) |
Recommend being evaluated for transplant | 1220 (81.3) |
Recommend learning more about transplant | 1197 (79.8) |
Provide handouts/brochures about transplant | 858 (57.2) |
Refer patients to an educational program at a transplant center/kidney organization | 857 (57.1) |
Distribute transplant center phone numbers | 806 (53.7) |
Have a detailed discussion about the advantages/risks of living donation | 497 (33.1) |
Have a detailed discussion about the advantages/risks of deceased donation | 488 (32.5) |
Display transplant posters in waiting room | 376 (25.1) |
Provide education to share with prospective living donors | 375 (25) |
Offer an opportunity to talk to kidney recipient | 349 (23.3) |
Provide list of transplant websites | 307 (20.5) |
Show transplant video(s) | 143 (9.5) |
Table 4. Barriers for conducting transplant education
The most common provider barriers faced by providers in transplant education were: 1) completing other work priorities (50%), 2) difficulty in education patients who were unable to speak English (48%) and 3) providers not having enough time to educate 5 patients (37%).
Common patient barriers encountered were: 1) patients having no family or friends who were willing to donate (46%), 2) patients having no family or friends without risk factors (43%), 3) their patients fearing loss of the benefits if they obtain a transplant (41%) and their patients’ inadequate health coverage to cover the cost of transplant (39%).
The most common system barriers faced were 1) inability to speak Spanish fluently to educate Spanish speaking patients (32%), and 2) poor communication with the nearby transplant center (28%). The results of aim 3 for most common provider barriers, patient barriers and system barriers are illustrated in Table 4.
Note: barriers are ONLY asked during the post surveys (can not compare pre and post ET).
Table 3. Educational practices among main educators (N=1495) | |
var | N(%) |
pb_othwkd | 751 (50.1) |
pb_noengd | 703 (46.9) |
pab_nofamwilld | 691 (46.1) |
pab_loseinsd | 671 (44.7) |
pab_nofamrskd | 650 (43.3) |
pb_diffd | 622 (41.5) |
pab_noinsd | 564 (37.6) |
pb_notimed | 553 (36.9) |
sb_spanishd | 537 (35.8) |
sb_noDVDd | 407 (27.1) |
sb_poorcomd | 403 (26.9) |
pab_toomanyd | 326 (21.7) |
sb_txcfard | 316 (21.1) |
pb_dontseed | 253 (16.9) |
sb_nopartd | 226 (15.1) |
pab_ptnoldd | 223 (14.9) |
pab_ptnoddd | 186 (12.4) |
sb_nosupedd | 171 (11.4) |
sb_valued | 139 (9.3) |
pab_nocandd | 99 (6.6) |
sb_nosupLDd | 66 (4.4) |
Dialysis providers’ knowledge - pre and post ET
Paired t-test results suggest providers’ knowledges after ET class are significantly increased by 5.6 points on average than knowledge before ET class, p < 0.001 (Paired t test).
##
## Paired t-test
##
## data: df.uniq.id$totknowpost and df.uniq.id$totknowpre
## t = 82, df = 1452, p-value <2e-16
## alternative hypothesis: true difference in means is not equal to 0
## 95 percent confidence interval:
## 5.5 5.8
## sample estimates:
## mean of the differences
## 5.6
Comparisons, Pre and Post ET
Generally, after ET training, providers are more likely to “consider patient edu as a priority”,“feel knowledgable”, “confident in their ability to educate”, “have excellent materials available”.
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End of first paper draft
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Geocoding of participating dialysis centers
Using provider reproted adreesses, we sucessfully Geo-coded 1936 non missing Coordinates suing Google Map API service.
leaflet version - the interactive map
## lon lat
## 1 -79 44
## 2 -71 43Figure 1. Partcipating centers + ET traning sites
Six Month Followup
We have 468 completed 6 month follow up records from redcap (123 donors did not actually complete their surveys).
Explore Transplant Usage
Please answer the following questions for all the dialysis centers you cover referring to Explore Transplant education actions you have taken since attending the Explore Transplant Training.
- 43% Share Explore Transplant materials and videos with your dialysis team (e.g., through an in-service)?
- 77% Determine which of your patients are transplant candidates?
- 87.2% Determine which of your patients are already on the transplant waiting list?
- 54% Hang Explore Transplant posters in the waiting room(s) of your dialysis center(s)?
- 33% Give Explore Transplant postcards to all transplant candidates to see if they are interested in being educated?
## x n percent valid_percent
## 1 Yes 199 42.5% 42.7%
## 2 Yes 360 76.9% 77.1%
## 3 Yes 408 87.2% 87.6%
## 4 Yes 251 53.6% 53.9%
## 5 Yes 152 32.5% 32.6%Number of Patients Educated using ET
How many new english/spanish patients have you educated? How many established english/spanish speaking patients have you educated in the below category?
- NEW English-speaking patients?
- NEW Spanish-speaking patients?
- ESTABLISHED English-speaking patients?
- ESTABLISHED Spanish-speaking patients?
- Total new patients educated: 1965, mean = 4, median = 0 (range 0 - 69).
- Total ESTABLISHED patients educated: 3062, mean = 7, median = 0 (range 0 - 215).
- total (new + established) patients educated: mean = 11, median = 2, total = 5027.
- 40% providers reported educating >= 5 patients using ET materials.
## # A tibble: 1 x 4
## mean sd median sum
## <dbl> <dbl> <dbl> <dbl>
## 1 4.20 8.63 0 1965## # A tibble: 1 x 4
## mean sd median sum
## <dbl> <dbl> <dbl> <dbl>
## 1 6.54 19.7 0 3062## # A tibble: 1 x 4
## mean sd median sum
## <dbl> <dbl> <dbl> <dbl>
## 1 10.7 25.0 2 5027## df_6mo$ed_total_bi n percent
## < 5 282 0.6
## >= 5 186 0.4How is ET materials used - common practises
How did you use the Explore Transplant materials at your dialysis center(s)?
Most commonly, providers give the ET materials to patients to take home (36.1%), or by combining the four meetings into fewer sessions(16.5%), or by making the ET materials available in the waiting room (9.2%). Only 7.3% present the materials like the program was designed, 4.7% actually play the DVDs, and 1.9% include ET materials in welcoming packets.
## ET use n percent
## 1 Total 468 -
## 2 By giving Explore Transplant materials to patients to take home 169 36.1%
## 3 By combining the four meetings into fewer sessions 77 16.5%
## 4 NA 65 13.9%
## 5 By making Explore Transplant materials available in the waiting room 43 9.2%
## 6 Other 39 8.3%
## 7 By presenting four meetings like the program was designed 34 7.3%
## 8 By playing the DVDs on closed circuit television 22 4.7%
## 9 By educating multiple patients at one time in a group setting 10 2.1%
## 10 By including Explore Transplant materials in new patients' welcome packets 9 1.9%Provider Efficacy
- Educating patients about transplant is an important priority for me.
- I am sufficiently knowledgeable about transplant that I could answer most patients’ questions.
- I am confident in my ability as a transplant educator.
- I have excellent transplant education materials available at my dialysis center(s) for patients.
Generally, 80% (76% - 87%) providers somewhat agree or strongly agree with the above statements.
## efficacy x n percent
## 1 Educating patients about tx is an important priority for me Somewhat Agree/Strongly Agree 406 86.8%
## 2 I am sufficiently knowledgeable about tx Somewhat Agree/Strongly Agree 381 81.4%
## 3 I am confident in my ability as a tx educator Somewhat Agree/Strongly Agree 358 76.5%
## 4 I have excellent tx education materials available at my dialysis center(s) Somewhat Agree/Strongly Agree 402 85.9%Education Plan?
In the next 6 months, do you plan to educate at least 5 additional patients using Explore Transplant?
Over half (53.6%) of providers plan to educate at least 5 additoinal patients using ET in the next 6 months.
1, Yes
2, No, all my patients have been educated and I will not have any new transplant referral candidates in the next 6 months.
3, No, although I have more patients to educate, I am not using the Explore Transplant program
4, Don't Know
## . n percent valid_percent
## 1 1 251 53.6% 54.0%Was ET Helpful?
- How helpful were the Explore Transplant DVDs for educating patients?
- How helpful were the Explore Transplant print materials for educating patients?
- How helpful was having Explore Transplant materials in Spanish for educating patients?
- How helpful was the Explore Transplant Program overall for educating patients?
70% providers reported that the ET program overall is helpful, 69.4% thought the print materials were helpful, 58.3% considered ET DVDs to be helpful, and only 43.6% thought ET materials in Spanish to be helpful.
## Helpfulness n percent
## 1 Explore Transplant DVDs 273 58.3%
## 2 Explore Transplant print materials 325 69.4%
## 3 Explore Transplant materials in Spanish 204 43.6%
## 4 Explore Transplant Program overall 330 70.5%Recommend
87.4% reported likely or definitely will recommend to colleagues.
## df_6mo$recommend6m n percent valid_percent
## 1 Not at all 7 1.5% 1.5%
## 2 Probably not 4 0.9% 0.9%
## 3 Neutral 43 9.2% 9.3%
## 4 Probably 105 22.4% 22.7%
## 5 Definitely 304 65.0% 65.7%
## 6 <NA> 5 1.1% -Provider Barriers
Majority (66%) of providers reported that they have difficulty rolling out the 4-part ET education to their patients. 47% reported they have competing work priorities prevented them from educating 5 patients using ET.
Other analysis
- Instead of comparing Waitlisting rates among those pledged to educate 5 and more patients with ET and those who did not, do a subset analysis in the actually educated >= 5 vs < 5 group using the 6 month followup data.
Resources
Notes
Some data cleaning notes for myself.
- Among those who claim to be directly educating patients, there are 869 (58.1%) unique attendee IDs(out of 1495).
Code snippets from JG sas file -
*Who does training beside yourself;
*0, Medical Director/Physician | 1, Nurse Manager/Facility Administrator | 2, Nurse (RN/LPN/MSN/APN) |
*3, Dietician | 4, Social Worker (MSW) | 5, Dialysis Technician | 6, Other (please specify);
if transplant_educators___0 = 1 then mdeduc = 1; else mdeduc = 0;
if transplant_educators___1 = 1 then faeduc = 1; else faeduc = 0;
if transplant_educators___2 = 1 then nurseduc = 1; else nurseduc = 0;
if transplant_educators___3 = 1 then dieteduc = 1; else dieteduc = 0;
if transplant_educators___4 = 1 then sweduc = 1; else sweduc = 0;
if transplant_educators___5 = 1 then techeduc = 1; else techeduc = 0;
if transplant_educators___6 = . then otheduc = 0; else otheduc = 1;
otheduc2 = educators_oth_spec;
if educator = 1 then new_educator= 1;
else new_educator = 0;
*Detail Discussion Educator;
*subset of Q16;
if advrskdd= 1 or advrskld= 1 then detail_edu= 1;
else detail_edu = 0;
*Educate at least one in the past 6-months;
if edneweng1 = 1 or ednewsp1 = 1 or edesteng1= 1 or edestsp1= 1 then edu_one = 1;
else edu_one = 0;
* 11/20/2012 New General Educator;
* Q10 and/or Q14 and/or Q15;
if educator = 1 or edneweng1 = 1 or ednewsp1 = 1 or edesteng1= 1 or edestsp1= 1 then new_gen_edu= 1;
else new_gen_edu= 0;