Implementation Science

Implementation Science for Kidney Disease at Penn/CHOP is at the forefront of applying implementation science to kidney disease care. By focusing on the practical application of evidence-based interventions, the division aims to enhance the quality of care for patients with kidney disease, electrolyte disorders, and hypertension.

At the core of this effort is the integration of new research findings into routine clinical practice. Our specialists work on creating and implementing innovative care models to address various aspects of kidney disease management, such as early detection, patient education, lifestyle modification, and blood pressure control. We also focus on improving patient adherence to treatment regimens and optimizing the use of healthcare resources.

1. Expanding equitable access to home dialysis

Home dialysis (both peritoneal dialysis and home hemodialysis) has been associated with similar or better quality of life at lower costs compared to in-center hemodialysis, yet only 13% of patients receive home dialysis in the United States. Recognizing the advantages of home dialysis, the federal government issued an executive order in 2019 (the Advancing American Kidney Health Initiative) to increase home dialysis and kidney transplantation use to 80% of new patients with kidney failure by 2025. Our research in home dialysis is focused on understanding barriers to home dialysis within the US to inform and test novel strategies to expand equitable access to home dialysis for patients with kidney failure. 

2. A Hybrid Type 1 Effectiveness-Implementation Study of Education Strategies for Vascular Access Creation in Advanced Kidney Disease

Over 750,000 people in the US have kidney failure, and most are treated with hemodialysis. Despite evidence-based guidelines recommending hemodialysis initiation via an arteriovenous (AV) vascular access (fistula or graft), 80% of US patients start hemodialysis with a central venous catheter, resulting in significant morbidity, mortality, and healthcare system expense. Additionally, there are stark racial disparities in the timely creation of AV access. Black patients are 20% less likely than White patients to start hemodialysis with a fistula despite, on average, being younger and having fewer comorbidities. Patients report delaying AV access surgery because of fear, reluctance to start dialysis, and worries about disfigurement, needles, and pain, as well as having an insufficient understanding of vascular access. To date, interventions aiming to increase uptake of the evidence-based recommendation for pre-dialysis AV access creation have focused on systems rather than patients, leaving unmet the well-documented educational and emotional needs of patients. Our central hypothesis is that strengthening patient preparedness through tailored AV access education and support will improve rates of AV access creation prior to hemodialysis initiation and reduce racial disparities. Applying well-established frameworks, we will conduct a hybrid type 1 effectiveness-implementation study of a user-tested, efficacious education package that provides vascular access health information and validates common patient emotions, with and without augmentation through motivational interviewing (MI). Specifically, we will conduct a 3-arm, parallel group, randomized trial of 3 education strategies: focused vascular access education (Education), MI-enhanced vascular access education (Education-Plus), and no focused vascular access education (Usual Care) among patients with advanced CKD at two health systems to 1) compare the effectiveness of Education, Education-Plus, and Usual Care for increasing the proportion of patients with pre-dialysis AV access creation, and 2) identify factors influencing the implementation of the education strategies in order to guide their equitable translation to the non-trial setting. We will evaluate the education strategies by examining relevant elements of the RE-AIM framework: Reach, Effectiveness, and Implementation. Importantly, we will determine whether and why these elements differ for Black and White patients. This research will yield critical effectiveness data about patient-focused education strategies to improve vascular access outcomes, and actionable information about implementation that will accelerate the equitable uptake of our findings, address disparities in vascular access care, and inform the delivery of other education content to patients with advanced CKD.

3. Impact of health behaviors and modifiable risk factors in the development and management of chronic kidney disease

Our research focuses on the impact of health behaviors and modifiable risk factors in the development and management of chronic kidney disease (CKD) and its complications, as well as addressing implementation gaps of evidence-based care in CKD. We have contributed to the growing evidence base that seeks to prioritize behavior recommendations for management of CKD as well as assessing barriers to healthy behavior engagement. We have conducted studies that have identified high levels of substandard health behavior engagement among adults with CKD and phenotypes of behavior engagement that associate with clinical outcomes in this population. Our work also has assessed for real-time barriers to health behaviors by interviewing patients with CKD and developing a patient-centered behavioral intervention that leverages mobile health technology to increase engagement in healthy behaviors. We are currently conducting feasibility testing of the intervention in a clinical trial. Our research aims to address implementation gaps in evidence-based CKD care. We are currently expanding Our investigations in disease management by exploring the impact of functional status among those with CKD and multi-morbidity. Our future work aims to guide the development of innovative strategies to improve clinical and patient-reported outcomes in CKD.

4. Translational research in acute kidney injury and kidney disease

We conduct translational research in the areas of acute kidney injury, critical care nephrology,  and kidney replacement therapies. Our team has a background in biomedical engineering and mathematics, which fueled our focus on improving advanced dialysis techniques. Our present work involves leveraging advanced optical techniques to examine how fluid removal during hemodialysis impacts plasma refilling, cardiac function, and cerebral perfusion. Our work aims to better evaluate the physiologic response to dialysis and to ultimately develop protocols to guide the management of dialytic therapy in the inpatient setting and minimize the adverse effects of hemodialysis.