VCOM Carolinas Research Day 2023

Clinical Studies

Exploring the Relationship Between Website Quality and Equity in Living Donor Kidney Transplant Lisa M. McElroy, MD, MS, 1 Keenan Caddell, OMS-II, 2 Christine Park, MS-3, 1 Nicole DePasquale, PhD, 3 Dinushika Mohottige, MD, 4 L. Ebony Boulware, MD, MPH 3 1 Division of Abdominal Transplant, Department of Surgery, Duke University; 2 Edward Via College of Osteopathic Medicine, Carolinas Campus; 3 Division of General Internal Medicine, Department of Medicine, Duke University; 4 Division of Nephrology, Department of Internal Medicine, Duke University

Abstract # CLIN-5



Introduction: Patient education and outreach are essential tools to eliminate health disparities. Living donor kidney transplant (LDKT) is the preferred treatment for patients with advanced chronic kidney disease (CKD). Racial disparities in LDKT have persisted for decades, with Black patients being less likely to undergo LDKT despite a higher incidence of advanced CKD. Drivers include patient knowledge of LDKT and ability to identify suitable donors. With access to the internet being nearly universal, the web serves as a ubiquitous source of information. This extends to healthcare, where health system websites are frequently visited for health education and to guide decisions. As such, websites can be a vital tool for outreach. Patient and donor education, center communication, and initiation of the donor evaluation process may all be facilitated via a transplant center’s website, but the extent to which transplant centers use their websites to do so is unknown. We hypothesized that transplant center website quality would be associated with equitable access to LDKT. Methods: This was a cross-sectional study of transplant center public-facing websites to characterize the information provided about LDKT. We examined active accredited adult LDKT programs in the United States identified through the Organ Procurement and Transplantation Network (OPTN) in March 2021. We created an assessment tool for website quality across three domains: accessibility (ease of access to LDKT-specific information from the main transplant center website), readability (ease of reading and clarity), and educational content related to LDKT (appropriateness and presentation of content as measured by the suitability assessment of materials (SAM) adapted for chronic kidney disease). Coders manually reviewed each website as accessed via the center-specific link provided by OPTN. We described categorical variables with frequency counts and percentages & continuous variables with medians, first quartile, third quartile, and minimum/maximum. The Pearson correlation method was used to assess relationships amongst the variables. Results: Among the 185 transplant center websites reviewed, 23.2% had a LDKT-specific hyperlink listed on the OPTN webpage and 14.6% of LDKT sites could be accessed directly from the main transplant center webpage. The median SAM score (scale 28-86) was 45 (IQR 4) and the median Flesch-Kincaid grade level (scale 0-18) and ease score (scale 0-100) were 9.1 (IQR 0.8) and 51.2 (IQR 5), respectively. We found that adherence to equity-promoting principles within educational content showed the highest correlation with LDKT black-to-white ratio ( r =0.25), total kidney transplant volume ( r =0.21), DDKT volume ( r =0.2), LDKT volume ( r =0.19), and LDKT-to-total transplant ratio ( r =0.12). Conclusion: Our study adds to the mounting evidence that points to a need for improvement in patient-facing educational materials about organ transplant. Related to LDKT, web-based educational content may be an important aspect of multi-component, multi-level interventions to improve equity in access to organ transplantation.

Figure 1. Correlations Between Study Variables

Table 1. Transplant Center and Website Characteristics


Values (n=185) 67 (38, 109) 16 (7.5, 28.5)

DDKT volume, median (Q1,Q3) LDKT volume, median (Q1,Q3) LDKT B/w ratio, median (Q1,Q3) Participation in NKF voucher, n (%) Y Participation in paired exchange, n (%) Y N

0.3 (0, 0.4)

86 (46.5) 99 (53.5) 43 (23.3) 142 (76.8)


Accessibility OPTN website links to transplant-specific page, n (%) Yes

43 (23.2) 142 (76.8)


Number of clicks to reach LDKT webpage from starting page, n (%) 0-1

27 (14.6) 53 (28.6) 69 (37.3) 28 (15.1) 8.0 (4.3) 128 (69.2) 33 (17.8) 24 (13.0)

2 3 4

5 or more

Number of LDKT-specific web page URLs, n (%) 1-4




Readability Overall Readable ® score (max 4), median (Q1,Q3)

• Access to the web is nearly universal in the United States (US). • Health system websites are useful tools for education and outreach. • Living donor kidney transplant (LDKT) is the best treatment for end-stage renal disease (ESRD), but it is underutilized by black patients, who have a higher incidence of ESRD. • Transplant center websites may be effective means to facilitate equity in access to LDKT.

3.0 (3.0, 3.0)

Mobile compatibility, n (%) Superior

1.0 (0.5) 183 (98.9)

Adequate Inadequate

This matrix displays correlations between transplant center characteristics (e.g., LDKT volume) and website quality measurements (e.g., equity). Adherence to equity-promoting principles within educational content showed the highest correlation with LDKT black-to-white ratio ( r =0.25), total kidney transplant volume ( r =0.21), DDKT volume ( r =0.2), LDKT volume ( r =0.19), and LDKT-to-total transplant ratio ( r =0.12).

0 (0)

Flesch-Kincaid grade level (max 18), median (Q1,Q3) Flesch Reading Ease score (max 100), median (Q1,Q3)

9.1 (8.3, 10.0) 51.2 (46.2, 55.6)

Educational Content SAM (max 86), median (Q1,Q3) Education (max 17), median (Q1,Q3)


45 (41, 49) 8.0 (4.0, 11.0)

LDKT program characteristics (max 5), median (Q1,Q3) 3.0 (2.0, 3.0) Adherence to equity-promoting principles (max 12), median (Q1,Q3) 3.0 (1.0, 4.0)


• The majority of transplant center LDKT program websites: • Were not directly accessible via the OPTN-provided link • Required three or more clicks to reach a LDKT-specific webpage • Had a high reader burden (i.e., used words difficult to understand) • Lacked suitable and sufficient LDKT educational content • There is a need for improvement in patient-facing educational materials about organ transplant; this includes providing content in languages other than English. • Web-based educational content should be included as part of future comprehensive interventions to improve equity in access to LDKT.

• Transplant center website links for all 185 active accredited adult LDKT programs in the U.S. in March 2021 were obtained via OPTN’s public -facing website. • We created an assessment tool to evaluate website quality across three domains:

Key Area of Deficiency:

100% of Websites Had Adequate or Superior Mobile Compatibility

Most websites: difficult to access high reader burden inadequate LDKT education

• Accessibility • Readability • Educational Content Related to LDKT

Promoting Equity

• Using an established coding manual, coders manually reviewed each website and entered data into a custom Research Electronic Data Capture (REDCap) system. • Website quality measures were compared with transplant center characteristics (e.g., LDKT volume, LDKT black/white ratio) to understand correlations between variables.

This study was granted an exemption from further IRB review by the Duke University Health IRB under protocol Pro00106338. This research was supported by the National Institute on Minority Health and Health Disparities under Award Number U54MD012530 and a Harold Amos Medical Faculty Development Award from the Robert Wood Johnson Foundation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Acknowledgements


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