Elisa J. Gordon

Introduction: While kidney transplant disparities are well-documented, little is known about disparities in the evaluation process after referral. Electronic dashboards interfacing with electronic health records can disaggregate patient data to identify potential avenues for reducing disparities. This cross-sectional study assessed contextual and design factors that would inform implementation of an ‘Equity Dashboard’ at one transplant center. Methods: Clinicians, implementation science experts, and patients were interviewed. Qualitative data were analyzed using thematic analysis guided by the Consolidated Framework for Implementation Research. Quantitative data comprised primarily descriptive survey data collected during interviews. Results: Twenty clinicians/experts and 23 patients participated. Perceived facilitators included: Inner Setting constructs of mission alignment, culture, tension for change, compatibility, and structural characteristics; and Individual Characteristics construct of high-level leaders. Dashboard alignment was expected with institutional commitment to patient-centered care, center workflow, and leadership support. Perceived barriers included: Intervention Characteristics construct of costs; and Inner Setting constructs of access to knowledge and information, information technology infrastructure, and work infrastructure. Financial costs were expected to support information technology development, staff training and time, and interventions arising from dashboard findings. Conclusions: Our findings suggest that perceived barriers were largely modifiable while perceived facilitators were immutable and integral to the institution, which would facilitate dashboard implementation. Future research will evaluate dashboard implementation on patients’ transplant access.

Background: Artificial intelligence enables surgical robots to perform certain actions without surgeon control or semi-autonomously. Patient willingness to undergo surgery via an automated machine is a key barrier to adoption of emerging robotic technology. Further, semi-autonomous surgical robots raise numerous ethical concerns, yet little is known about patients’ perceptions of these issues. We assessed patients’ perceptions of ethical issues in semi-autonomous robot-assisted surgery (RAS) and how their perceptions would affect decision-making about undergoing semi-autonomous RAS. Methods: Adult patients who underwent surgery within the prior three years, with a non-autonomous robot or without any robot, were recruited via email. We conducted semi-structured teleconference interviews that included open- and closed-ended questions, to assess factors affecting patient decision-making and ethical concerns about semi-autonomous RAS, and demographics. Quantitative data were analyzed using descriptive statistics. Qualitative data were analyzed using thematic analysis. Results: Fifty patients participated. Most participants were female (62%), White (52%), and the mean age was 53. Most patients (56%) would undergo semi-autonomous RAS. However, willingness varied by which surgical process the robot would have control over. Many patients (46%) were highly willing to undergo semi-autonomous RAS when the robot has control over instruments. Four themes emerged about ethical concerns driving patients’ willingness to undergo semi-autonomous RAS: (1) desire for informed consent to express self-determination, (2) semi-autonomous RAS introduces new risks to procedures, (3) doctor-patient relationship and trust can facilitate patients’ willingness to undergo semi-autonomous RAS, and (4) semi-autonomous RAS comprises an important surgical innovation, conferring benefits. Conclusion: Our findings suggest that most patients would be willing to undergo semi-autonomous RAS. Willingness was related to ethical considerations of informed consent, perceived risks, level of surgeon versus robot control over surgical processes, doctor-patient relationship, and perceived benefits. Addressing patients’ perceptions of semi-autonomous RAS may facilitate greater integration of surgical robots into clinical practice.

Normothermic Regional Perfusion (NRP) is being used to expand the utilization of organs from donation after circulatory death (DCD) donors and improve transplant outcomes (Bekki et al. 2023; Wall e...

Key Points: Apolipoprotein L1 genetic testing did not reduce potential living donors' willingness to donate, supporting integration of testing into practice. The Apolipoprotein L1 Testing and Counseling Program did not reduce potential living donors' decisional conflict or increase preparedness to donate. The trial demonstrated the feasibility of integrating apolipoprotein L1 genetic testing and counseling into routine living donor clinical evaluation. Background: Living donors of African ancestry have the highest risk of postdonation kidney disease. Apolipoprotein L1 ( APOL1 ) risk variants may contribute to this risk. This study evaluated the effectiveness and implementation of our culturally appropriate APOL1 Testing and Counseling Program to reduce potential donors' decisional conflict for donation. Methods: This prospective, nonrandomized, pre-post two-site hybrid type 2 effectiveness-implementation study evaluated the effect of the intervention on decisional conflict about donation, preparedness for decision making about donation and for donation, willingness to donate, and satisfaction with informed consent among potential donors of African ancestry undergoing evaluation. The intervention involved donors: using a chatbot providing APOL1 information, receiving culturally competent counseling, and APOL1 genetic testing. Control arm received routine care. We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to longitudinally evaluate implementation outcomes assessed through validated surveys with donors and electronic health record review using linear mixed effects models. Cross-sectional outcomes were assessed using multiple regression models. Results: We enrolled 280 potential donors (75 control arm, 205 intervention arm; 71.07% participation rate). More were female (59%) and had a mean age of 40.2 years (SD, 12.8). No significant differences emerged in most primary and secondary outcomes between the intervention and control groups (decisional conflict β [95% confidence interval (CI)], −1.05 [−4.13 to 2.03]; P = 0.50), preparation for decision making ( β [95% CI], −7.02 [−18.83 to 4.78]; P = 0.24), preparedness to donate ( β [95% CI], 0.04 [−0.48 to 0.56]; P = 0.89), willingness to donate ( β [95% CI], 0.18 [−0.29 to 0.66]; P = 0.45). The right amount of information to make a decision domain for satisfaction with informed consent was significantly lower in the intervention arm ( β [95% CI], −0.34 [−0.65 to −0.02]; P = 0.04). Conclusions: Our APOL1 Testing and Counseling Program had no effect on potential donors' willingness to donate regardless of undergoing APOL1 testing, demonstrating the feasibility of its integration into routine donor clinical evaluation. Clinical Trial registry name and registration number: NCT04910867.

Introduction: Living donor liver transplantation is expanding worldwide as a treatment for end-stage liver disease, especially in high-risk recipients. No standardized information is provided to donors during the informed consent process. Consequently, variable information may be provided to the donor about the recipient, which may undermine donor-informed consent. Research Questions: In high-risk donation scenarios, it is uncertain whether information disclosed about the recipient is sufficient for donor-informed decision-making. Would information about the recipient's potential adverse and beneficial short- and long-term outcomes help donors make a decision about donating? Design: An online survey was conducted of previous living liver donors’ likelihood of donating and information needs regarding their recipients in 3 hypothetical high-risk clinical scenarios: alcoholic liver disease (ALD) with high relapse risk, acute liver failure (ALF), and hepatocellular carcinoma (HCC) with high recurrence risk. Results: A total of 98 living liver donors participated in this study. Most living liver donors expressed willingness to donate to a patient in each scenario: ALD (51%), ALF (56%), and HCC (85%). Most living liver donors (56% to 93%) reported desiring information about the recipient's diagnosis, clinical condition, and projected outcomes in their donation decision-making process. Most living liver donors (82%) considered an acute consultation service to be useful in deciding whether to donate to a patient with ALF. Conclusions: The findings suggested that transplant programs should incorporate recipient health information with recipient consent into the informed consent process and offer consultation services to support living liver donors’ decision-making.

Background.: Transplant center processes for determining candidacy are complex, poorly documented, ambiguous, and variable across centers. Opaque and nonstandardized transplant processes can compromise data collection and lead to inconsistent outcomes. Methods.: To understand process variation and data quality in transplantation, we surveyed 8 abdominal transplant centers in an existing research consortium about their processes of care for liver, kidney, and pancreas transplants. We used the Systems Engineering Initiative for Patient Safety model to identify variation related to people, tasks, tools, environment, and processes. Results.: Centers varied in their processes across phases of transplant care, including screening referral, waitlist maintenance, and posttransplant follow-up. Regarding referrals, transplant centers chose their locations for outreach to and education for referring providers based on historical density or by request (63%). Additionally, screening of referred patients for transplant evaluation varied across centers related to screening method, screening timing/attempts, and who determines eligibility. For patients declined for listing, only 25% of centers had a formal appeal process (liver only), and most centers had either an informal appeal process (liver: 50%, kidney and pancreas: 87.5%) or none (liver: 25%, kidney and pancreas: 12.5%). Conclusions.: In light of increased national attention to improving data collection, processes of care, and workforce efficiency, our findings provide insight into processes that may inform effective transplant practices and identify targets for future interventions.