The transplant candidate work-up is a long and complex process that slows down the final listing of transplant patients. Cardiology evaluations, screening tests, social work visits, and multiple other tests have to be coordinated to complete the process. A novel strategy was piloted at the Yale transplant program in the last few years and compared to the traditional method of evaluating transplant candidates. In a recent article in the American Journal of Kidney Diseases from Yale University Medical Center, this system resulted in a shorter listing time with less cost to the transplant center. Dr. Sanjay Kulkarni (SK) from Department of Surgery discusses this study with Dr. Kenar Jhaveri (eAJKD), eAJKD Blog Editor.
eAJKD: Can you summarize your results?
SK: We wanted to approach the listing of transplant patients in a creative efficient manner. There are established disparities demonstrating that groups of patients take longer to be placed on the waitlist and thus have less access to kidney transplantation. We designed a 1-day pretransplant work-up strategy as a quality improvement study. A 1-day centralized work-up was implemented on July 1, 2007, whereby the transplant center coordinated the necessary tests needed to fulfill minimal listing criteria. This coordinated pretransplant work-up model significantly decreased time to listing for kidney transplant based on our findings. Our standard listing time for all comers prior of the intervention was approximately was 250 days. A study by Weng et al in AJKD suggested that that’s roughly the proportion of time where 50% of the patients would get listed. Our study showed that the 1-day centralized intervention pre-work decreased the time to listing to 42 days.
eAJKD: Can you describe in detail to us the “1-day pretransplant experience”?
SK: It starts at 8 AM and ends by 1-2 PM:
- 8:00 AM: Consent followed by 30 minutes of presentation by the surgical staff on kidney transplantation. This discusses the risks, the benefits, the overview, the listing process, complications, and so forth.
- 9:00 AM: Presentation by our transplant pharmacist to discuss the specific medications.
- 9:30 AM: Presentation by the dietician on the importance of dietary goals, both pretransplant and posttransplant, and to discuss our body mass index protocol.
- 10 AM-1 PM: Patients disperse to different sections (sonogram, social worker evaluation, transplant nephrology evaluation, blood work, ECGs)
If a determination is made during the medical evaluation that the patient require additional cancer screening and or a specific consultation, the appointments are made. For example, if they required a colonoscopy, we would give them the education, the prep instructions, and the appointment. Our infrastructure with an infusion center and a large number of consult rooms allows for this degree of flexibility. As a result we can see 10-12 patients per day.
eAJKD: How do the patient’s react to this one day visit experience?
SK: From a patient perspective, they are very appreciative of this system. The response has been overwhelmingly positive. A positive perception of organization and planning is noted. The conference room where we house the patients has breakfast and food as they are spending a fair amount of time there. We are able to cover education, complete the vast majority of the work-up, and get the patients on the list quickly. This method effectively allows us to have patients seen on one particular day with all necessary testing completed.
eAJKD: Do a fair amount of patients feel a sense of “information overload”?
SK: Yes, there were a minority of patients who felt that way. Even though we had prepared them and announced that they shall be there almost the entire day, many patients still weren’t necessarily prepared for it. Most of the patients, however, found it really gratifying.
eAJKD: What barriers did you face in creating this 1-day pretransplant evaluation?
SK: Many barriers were encountered. We had to really get buy-in from our local nephrologists. One of the things we were particularly sensitive to was the practice patterns of our local nephrologists in both completing this type of work-up for the patients, and also referring their patients to specialists of their choice. We didn’t want to be perceived as creating an environment where we duplicate resources unnecessarily, disrupt other practice patterns, and contribute to discontinuity of care. Prior to the initiation of this system, we explained the problem of access to kidney transplantation. Also, we defined a clear dividing line stating that we will use our own referring doctors for the purposes of clearance only, and that if there’s any adoption of care or any further medical care, then that would be the per view of the nephrologists and their local practice.
eAJKD: Many centers use the time and effort made by patients to complete the pretransplant work-up a marker of compliance. Any thoughts on that concept?
SK: We feel fundamentally that that’s the wrong approach. There are far too many issues, both financial and logistical, for those patients and drawing such conclusions is not correct. We don’t think it is a valid marker for patient compliance.