How to Leverage Implementation Science to Achieve Equity in Nephrology Care Delivery

Abstract

There are several evidence-based practices within nephrology that have the potential to meaningfully improve patient outcomes and mitigate disparities. However, these practices are inconsistently implemented in routine care, contributing to low-quality care, persistent health disparities, and high healthcare costs. To address these care gaps quickly, nephrology would benefit from leveraging implementation science: a multidisciplinary field that seeks to close the gap between evidence and practice by examining the optimal approach to help individuals, groups, organizations, and communities implement evidence-based interventions in real-world settings. This Perspective is designed to provide an overview of the field of implementation science and summarize how to apply implementation science in nephrology to address health disparities. To illustrate how to leverage implementation science for health equity, we also showcase two case examples focused on 1) addressing disparities in the use of sodium/glucose cotransporter-2 inhibitors (SGLT2 inhibitors) to slow the progression of chronic kidney disease, and 2) increasing equitable access to home dialysis for people with kidney failure.

With rising Medicare expenditures for kidney failure—currently at $52.3 billion—there is an urgent need for strategies in nephrology that can improve quality, narrow inequities, and stem healthcare costs.¹ For example, in the United States, only 11.5% of potentially eligible patients receive sodium/glucose cotransporter-2 inhibitors (SGLT2is) and 13.4% of patients with new kidney failure receive home dialysis – both of which are evidence-based treatments that may improve quality at similar or lower long-term costs.^1–3 Additionally, from an equity perspective, Black patients are significantly less likely to receive SGLT2is and are 31% less likely to receive peritoneal dialysis, even though Black patients are 3.4 times more likely to develop kidney failure, compared to White patients.^3–7 It is particularly important to develop strategies to address these disparities, as it can take an average of 17 years for evidence-based interventions—such as the use of SGLT2is to slow CKD progression—to be routinely implemented into practice.^8,9 To address these care gaps, nephrology would benefit from approaches intentionally designed to address gaps in practice, such as implementation science: a multidisciplinary field that seeks to close the gap between evidence and practice by examining the optimal approach to help individuals, groups, organizations, and communities implement evidence-based interventions into routine clinical settings.^10–12

In this Perspective, we will 1) provide an overview of the field of implementation science; 2) summarize why and how to apply implementation science in nephrology with a focus on its role in promoting health equity; and 3) use case examples to outline the value of integrating a health equity lens into implementation science.

What is implementation science?

Implementation science is the scientific study of methods to promote the systematic uptake of evidence-based interventions into routine practice.¹² Implementation science research is distinct from traditional clinical trials in that implementation science focuses on how to help individuals, groups, or organizations to change behavior, address barriers, and/or adopt new interventions within a given setting, instead of focusing solely on whether an intervention is effective.

To understand implementation science, one must understand several key concepts.^10,13,14 While detailed primers on these concepts already exist, we summarize them below and in Table 1.^10,15 Implementation strategies are actions taken to enhance the adoption, implementation, and sustainability of an evidence-based intervention. Evidence-based interventions refer to interventions with demonstrated efficacy and effectiveness, such as prescribing SGLT2is to slow CKD progression.

Table 1:

Implementation science key definitions with nephrology examples

Implementation Science Term	Definition	Nephrology Examples
Effectiveness research	The evaluation that the intervention achieves its intended clinical outcomes; typically tested using clinical trials	EMPA-KIDNEY trial25
Evidence-based intervention (EBI) or practice (EBP)	A novel intervention with demonstrated efficacy and effectiveness	SGLT2 inhibitors slow the progression of chronic kidney disease
Implementation strategy	Actions taken to enhance adoption, implementation, and sustainability of an EBI59; a common taxonomy is the Expert Recommendations for Implementing Change (ERIC) which includes 73 strategies (e.g., audit and feedback); strategies should be clearly specified using best practices60	Audit and feedback to providers on prescribing patterns for SGLT2is Peer support as a strategy to increase home dialysis use.
Implementation outcomes	Outcomes used to identify the success of implementation efforts; taxonomies include the Proctor Implementation Outcomes Framework and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) 57,60	Reach Effectiveness Adoption Implementation Maintenance
Theories, Models, and Frameworks (TMFs)	Help identify and select variables of importance throughout the implementation process; commonly categorized as determinant, process, or evaluation frameworks*.61	Determinant framework: SEIPS 3.0 - the Systems Engineering Initiative for Patient Safety, Health Equity Implementation Framework56 Process model: QUERI Implementation Roadmap (Quality Enhancement and Research Initiative) 16 Evaluation framework: RE-AIM - Reach, Effectiveness, Adoption, Implementation, and Maintenance57
Implementation research study	The overarching term for any evaluations which examine the best ways to promote the adoption and routine use of an EBI and examining implementation outcomes; may test implementation strategies	A cluster randomized adaptive implementation trial comparing the Replicating Effective Programs (rEp) strategy with REP plus telephone facilitation to promote the use of a population management tool for Veterans with severe mental illness62
Pre-implementation research study	An evaluation of current practices, which can include mixed-methods studies focused on systematically identifying barriers and facilitators to implementing an EBI or studies focused on identifying implementation strategies	IM-HOME study focused on identifying major barriers to home dialysis55
Implementation-effectiveness hybrid trial	Study designs which include evaluations of both the effectiveness of the EBI and assessment of the implementation process itself; the three types of hybrid designs may primarily emphasize effectiveness (Type 1), emphasize both effectiveness and implementation (Type 2), or emphasize implementation (Type 3).13,19	IMPROVE AKI Trial – a cluster-randomized implementation-effectiveness hybrid type 1 trial evaluating the role of team-based coaching and assistance on prevention of contrast-associated acute kidney injury23

^*Determinant frameworks guide the prospective or retrospective evaluation of the contextual setting within which the implementation is occurring.⁶¹ Process frameworks provide steps for getting research into practice. ⁶¹ Evaluation frameworks are used to identify and select implementation outcomes with the goal to assess the degree of success of the implementation effort.⁶¹ In the planning phase of an IS study, determinant frameworks can help to identify what factors may hinder and promote the ability of a site to adopt an evidence-based practice. Approaches like implementation mapping can help to systematically use this information to identify which implementation strategies to use.⁵⁸

In some cases, implementation scientists use qualitative and mixed-methods studies to understand why existing interventions are inadequately used in current practice and to help inform which implementation strategies may best meet the needs of patients and clinicians in different clinical settings (also called ‘pre-implementation evaluation’).^5,16 In these studies, implementation scientists often leverage conceptual theories, models, and frameworks (TMFs) to ensure that the study captures data on determinants that influence the implementation of evidence-based interventions. These TMFs, such as the Consolidated Framework for Implementation Research (CFIR), help researchers identify and understand variables that influence implementation.^17,18 For example, when studying barriers and facilitators to prescribing SGLT2is, one could use CFIR to ensure that the study captures the influence of the inner setting (e.g., the culture of the clinic) and the outer setting (e.g., prior authorizations and costs), as well as other CFIR domains.

In other cases, implementation scientists enhance traditional clinical trials by embedding implementation science principles to create hybrid effectiveness-implementation trials.¹³ These hybrid trials serve to address both effectiveness outcomes (e.g., do SGLT2is slow the progression of CKD?) and implementation outcomes (e.g., what factors influence the uptake of SGLT2is in clinical practice?).^13,19,20 Hybrid trials are study designs that include evaluations of both the effectiveness of an intervention and an assessment of the implementation process itself; the three types of hybrid designs may primarily emphasize effectiveness (Type 1), emphasize both effectiveness and implementation (Type 2), or emphasize implementation (Type 3).^13,19,20

Examples of implementation science in nephrology

While hybrid implementation trials are relatively limited in nephrology, the number of trials is growing. We describe two examples below.

The ASCENT study (Allocation System Changes for Equity in Kidney Transplant) is a cluster-randomized hybrid type 1 trial in which researchers leveraged a traditional clinical-effectiveness trial to primarily study the effectiveness of a multilevel educational intervention on improving equitable kidney transplant waitlisting.²¹ Using the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance), they also described barriers and facilitators to implementing the educational intervention (implementation outcomes).²²

The IMPROVE-AKI study (A Cluster-Randomized Trial of Team-Based Coaching Interventions to IMPROVE Acute Kidney Injury) is another cluster-randomized hybrid type 1 trial (Table 1 lists additional context).²³ Researchers studied the role of a coaching-based collaborative designed to improve the implementation of an acute kidney injury (AKI) prevention toolkit to reduce contrast-associated AKI. The primary outcome of the study was 7-day AKI (effectiveness outcome). Using CFIR, the researchers described barriers and facilitators to implementation in an accompanying qualitative study.²⁴ A more detailed discussion of hybrid trials is also outlined by Cervantes et al.²⁰

Why is it time to expand implementation science in nephrology?

Implementation science can be useful for both novel and long-standing evidence-based interventions in nephrology. Recently, ground-breaking clinical trials in nephrology have identified several novel evidence-based interventions in areas such as CKD progression (SGLT2is and finerenone), ^25,26,27 uremic pruritus (difelikefalin)²⁸, and hyperphosphatemia (tenapanor).²⁹ In parallel, epidemiologic research illustrates that long-standing evidence-based interventions remain underused—such as routine albuminuria measurement for patients with CKD (precluding the use of calculators such as the Kidney Failure Risk Equation),³⁰ home dialysis use in the United States,^1,31,32 and palliative care engagement for people with advanced illness in nephrology.³³ Incorporating implementation science principles early in the design and testing of interventions can help prevent the emergence of new evidence-to-practice gaps in clinical practice. Further, incorporating equity-focused implementation science principes may help narrow health disparities in clinical practice.

Nephrology is relatively new to the field of implementation science.^15,20 Specialties such as cardiology, oncology, general internal medicine, and infectious diseases have had much longer research funding and experience in implementation science.^37–42 This may explain the limited application of implementation science in nephrology, the persistent gaps in routine practice, and the limited published hybrid trials within nephrology.^20,23 To illustrate the potential value of investing in implementation science in nephrology, in Table 2, we list several excellent and robust clinical trials within nephrology and outline examples of how investments in implementation science methods in nephrology could have provided additional insights from these trials.

Table 2.

Examples of potential opportunities to better integrate implementation science into clinical trials within nephrology^*

Trial name	EHR alert trial for acute kidney injury63	SCAMP trial64	TiME trial65	Home dialysis implementation trial66
Innovation	Clinical decision support system to deprescribe potential nephrotoxins	Decision support tool to guide initiation of kidney replacement therapy	Longer hemodialysis sessions and impact on mortality	Four-component intervention designed to increase home dialysis use
Type of study	Multi-center randomized controlled trial	Single-center randomized controlled trial	Pragmatic multi-site randomized controlled trial	Cluster randomized controlled trial
How might the study be reframed to incorporate implementation science principles?	The clinical support system could be considered to be an implementation strategy, with deprescribing as the evidence-based intervention.	In addition to studying the effectiveness of the decision support tool, implementation scientists could consider the implementation outcomes of adoption, feasibility, and sustainability.	The study could be seen as having measured the implementation outcomes of fidelity and adoption for the intervention of providing longer hemodialysis sessions.	The four-component intervention could be considered to be a bundle of implementation strategies, with home dialysis as the evidence-based intervention.
If the study had resources to evaluate implementation outcomes, what additional evidence about implementation might be useful to collect?	In addition to evaluating the effectiveness outcome of reducing the rate of acute kidney injury, one could observe the implementation outcomes of implementation or adoption of the EHR-based alert system across sites.	Interviews with nephrologists could help to understand perceptions of SCAMP and the roll-out of SCAMP. These interviews could help to identify potential strategies that worked to increase/improve uptake. (e.g., identifying champions—local leaders who may have supported SCAMP by helping others understand the value of the practice).	This is one of the first large-scale pragmatic clinical trials in dialysis within the US. The study was highly successful at enrolling patients, capturing data, and measuring outcomes in a real-world setting. However, the study ended early because the duration of hemodialysis across the two arms was too similar to allow for a meaningful comparison of the two groups. Mixed-methods, such as qualitative interviews and surveys of patients and providers, could help understand determinants (barriers and facilitators) that influenced the ability to provide longer hemodialysis sessions (i.e., the acceptability of the intervention and the adoption of the intervention). These data could help the field understand how to improve fidelity in future pragmatic clinical trials within dialysis settings.	One approach to incorporate implementation science in this trial could be to focus on the implementation of these strategies, with outcomes such as acceptability of each component of the four-component strategy, fidelity to each component, and adoption of each component.
Example trial design#	Hybrid type 1	Hybrid type 1	Hybrid type 1 or 2	Hybrid type 3

Abbreviations: EHR, electronic health record; SCAMP, Standardized Clinical Assessment and Management Plan (for acute kidney injury); TiME, Time to Reduce Mortality in ESRD.

^*In the authors’ opinion, these trials are excellent and robust clinical effectiveness trials within the field of nephrology. In designing this Table, our hope is to showcase practical opportunities to use implementation science principles to further expand effectiveness trials. We do not intend to suggest that these trials were somehow inadequate. Rather, we seek to illustrate the value of investing in implementation research in nephrology, such that future trials could involve implementation researchers and dedicated funding for implementation science to allow for a rigorous evaluation of implementation outcomes on top of the existing rigorous evaluation of effectiveness outcomes.

^#Hybrid trials are study designs which include evaluations of both the effectiveness of an evidence-based intervention and assessment of the implementation process itself; the three types of hybrid designs may primarily emphasize effectiveness (Type 1), emphasize both effectiveness and implementation (Type 2), or emphasize implementation (Type 3).^13,19

To begin to address the limited use of implementation science in nephrology, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) hosted an implementation science and health equity workshop in October 2024 and announced a possible future training program called PrISHES (Program for Implementation Science and Health Equity Scholars).⁴³ However, more upfront investment is needed to help ignite a movement to improve the adoption of evidence-based practices in clinical care.

How can we apply implementation science principles to address health equity within nephrology?

Over the past decade, implementation scientists have had an increased focus on ensuring equitable implementation of interventions to meet the needs of a diverse patient population.⁴⁴ Within nephrology, implementation science can be leveraged to 1) understand adoption of existing nephrology evidence-based interventions; 2) inform the development, implementation, and evaluation of strategies to improve uptake of evidence-based interventions; and 3) address disparities in access to these interventions. Given the well-established, long-standing disparities in care among historically disadvantaged patients with kidney disease, implementation science is a potentially powerful approach to drive meaningful improvements in health equity.^45–49

Within nephrology, it may be challenging to directly associate implementation efforts to clinical outcomes without accounting for socioeconomic characteristics. For patients with kidney failure, it is challenging to design strategies based on an evidence-based intervention that is truly “one-size-fits all,” unless the strategies account for the social determinants that drive disparities in outcomes. Fortunately, the field of implementation science has grown to include equity-focused conceptual models and outcomes, such as the Health Equity Implementation Framework and the Equity-focused Implementation Research (EquIR) framework.^51–53 These models enable researchers to design and conduct studies that focus on 1) collecting data on social determinants of health and contextual factors that lead to health disparities, and 2) narrowing evidence-to-practice gaps among disadvantaged and historically excluded patient populations through strategies designed with community partners. These types of studies align with real-world care delivery and quality metrics—such as metrics from the Centers for Medicare and Medicaid Services—and may allow clinicians to understand what strategies best address inequities in nephrology. Equity-focused implementation strategies could ultimately enable the community to systematically deliver high-value care for all patients.

To further showcase how to integrate health equity into implementation science, in Table 3, we list sample research questions that could be addressed with principles of implementation science and health equity. Below, we also provide two detailed examples of implementation science studies, one hypothetical and one ongoing, that draw on equity-focused conceptual models for two evidence-based interventions: 1) SGLT2is to reduce CKD progression and 2) home dialysis use for people with kidney failure.

Table 3.

Practical examples from chronic kidney disease (CKD) and kidney failure of how to apply implementation science and health equity to nephrology care delivery

IS Term	Example from CKD	Example from kidney failure
Evidence-based intervention	SGLT2is are recommended to slow the progression of CKD for people with diabetes mellitus	Peritoneal dialysis, a dialysis modality for people with kidney failure, has similar or better health outcomes compared to in-center hemodialysis.
Current implementation challenge	Prescription of SGLT2is is low among eligible patients, with rates ranging from 10.7% to 11.5%	Peritoneal dialysis use within the US is 13.4%, which is lower than the federal goal and lower than similarly resourced countries
Example health equity challenge	Individuals of Black race and/or Hispanic ethnicity have significantly lower odds of being prescribed SGLT2is compared to individuals of White race.	Home dialysis use is significantly lower among individuals of Black race and/or Hispanic ethnicity, compared to individuals of White race.
Example implementation science research question	What is the role of an automated EHR-based default order set for SGLT2is in improving the uptake of SGLT2i prescriptions?	What is the role of peer support in addressing the low and disparate use of home dialysis? In this case, peer support may refer to a strategy where people experienced in peritoneal dialysis provide support to patients approaching kidney failure
Example implementation science study	A hybrid implementation-effectiveness randomized controlled trial evaluating the implementation of an automated EHR-based default order set for SGLT2i prescriptions	A hybrid implementation-effectiveness randomized controlled trial evaluating the implementation of peer support as a program to expand home dialysis use
Example of an effectiveness outcome	Reduced progression of CKD: Does the EHR-based default order set have an impact on rates of CKD progression related to SGLT2i use?	Home dialysis use: Does the peer support program have an effect on home dialysis use?
Example implementation outcomes	Adoption: How acceptable and easy-to-use is the EHR-based tool? Sustainability/Maintenance: What is the use of the EHR-based tool after the trial ends?	Reach: Among all eligible patients approaching kidney failure, what proportion of patients receive peer support?
Example of a health equity implementation outcome	Equitable Adoption: Which healthcare systems adopted the EHR-based tool? What prevented adoption in some settings? How did adoption of the tool differ in safety-net hospitals compared to higher-resourced hospitals?	Equitable Reach: Among all Black patients approaching kidney failure, what proportion of Black patients receive peer support?

Abbreviations: CKD, chronic kidney disease; EHR, electronic health record; SGLT2i, sodium glucose cotransporter-2 inhibitor

Example 1: Hypothetical example of increasing equitable uptake of SGLT2is.

Consider a hypothetical scenario where a nephrologist and clinic director, Dr. Lopez, oversees three clinics in a rural setting in which nephrologists care for over 1,500 patients with CKD. Dr. Lopez has educated her fellow nephrologists about the recent evidence from several clinical trials that demonstrate the effectiveness of SGLT2is for CKD (i.e., effectiveness research).^25,26 However, when Dr. Lopez reviews population-level data from her clinics, she finds that only 20% of eligible patients with CKD are prescribed SGLT2is, and only 10% of eligible Black patients are prescribed SGLT2is. To understand why her clinics have an overall low and inequitable rate of SGLT2i use, she reaches out to an implementation scientist to help her conduct a ‘pre-implementation evaluation.’

Together, they use the Health Equity Implementation Framework (i.e., a determinant framework) to assess what factors influence the low and inequitable use of SGLT2i in their clinics.^51,52 The Health Equity Implementation Framework broadly helps Dr. Lopez and her team to consider the factors that influence SGLT2i use, such as patient and provider factors, individual clinic factors, and healthcare system factors (Figure 1, Panel A). Additionally, the framework encourages individuals to focus on three key areas that may influence inequities: 1) culturally relevant factors (e.g., provider habits, experiences of systemic racism, education levels), 2) patient-provider interactions within the clinical encounter (e.g., trust/mistrust within the community, language barriers, clinic visit times), and 3) societal influences (e.g., sociopolitical factors including insurance coverage and access, physical structure/built environment including transportation options and access to pharmacies). Throughout this process, Dr. Lopez and her team identify the core components of the SGLT2i prescribing process, i.e., what needs to happen for someone to receive SGLT2i treatment.

Figure 1.

(A) Conceptual model for hypothetical example of SGLT2is in CKD. (B-C) HOME-R conceptual model and the application of HOME-R in a qualitative study. (A) outlines a conceptual model designed to inform implementation strategies to address disparities in SGLT2i prescribing. This model integrates the Systems Engineering Initiative for Patient Safety 3.0 (SEIPS 3.0) and the Health Equity Implementation Framework. Please note that this Figure is designed for illustrative purpose only. It is not an exhaustive list of determinants that influence SGLT2i prescribing in the US. (B) outlines a conceptual model, HOME-R, created to inform future implementation strategies for home dialysis. HOME-R uses constructs from two existing frameworks: the Systems Engineering Initiative for Patient Safety 3.0 (SEIPS 3.0) and the Equity-based framework for Implementation Research (EquIR). Briefly, HOME-R uses SEIPS 3.0 to define five phases of the patient journey to home dialysis: referral to home dialysis, education to decide whether to pursue home dialysis, training to learn how to do home dialysis, initiation of home dialysis, and maintenance/continuation of home dialysis. At each of these five phases, patients interact with system elements—providers, care partners, the dialysis machine and supplies, and the environment (e.g., the home or the home dialysis clinic)—all of which can serve as barriers or facilitators to home dialysis use. HOME-R also uses EquIR to identify and evaluate how social determinants of health (e.g., race, ethnicity, housing, employment) modify the influence of system elements on each phase of the patient journey to PD. (C) is an example of how we used HOME-R to inform a study. We planned a nationwide study where we performed in-depth site visits at home dialysis clinics across the country to understand barriers and facilitators to home dialysis use. The study involved direct observations, interviews, and procurement of home dialysis materials. We mapped key concepts from the HOME-R model to each form of data collection (using blue stars) to ensure we captured data relevant to the patient journey to home dialysis, the system elements affecting home dialysis use, and the social determinants known to drive disparities in home dialysis use.

Abbreviations: SGLT2i, sodium glucose cotransporter-2 inhibitors; CKD, Chronic kidney disease; HOME-R, Home dialysis conceptual model for implementation Research; EquIR, Equity-based framework for Implementation Research; PD, peritoneal dialysis; SEIPS 3.0, Systems Engineering Initiative for Patient Safety 3.0.

Dr. Lopez works with the implementation scientist to conduct interviews with providers and patients to understand barriers to receiving SGLT2is. In this process, they find that providers do not realize that they are prescribing SGLT2is less to their Black patients. They also find that providers and patients perceive that patients may be hesitant to take new medications due to historic mistreatment by the medical community.

After identifying the factors which influence the use of SGLT2is in the clinic, Dr. Lopez and her team develop a pilot implementation-effectiveness hybrid type 3 trial focusing primarily on the implementation outcome of prescribing SGLT2is within a rural setting and testing what implementation strategies may work best to ensure uptake of SGLT2is. They also plan to assess clinical outcomes to confirm that SGLT2is continue to work as designed for patients with CKD.

Based on the information they gathered from interviews, Dr. Lopez and her team decide to test a combination of two implementation strategies: 1) a provider-facing implementation strategy called ‘audit and provide feedback,’ where the implementation scientist will capture data on how often providers are prescribing SGLT2i to patients with CKD and provide individual data to providers on their prescribing rates for all patients, stratified for Black patients in their clinic; and 2) a patient-facing implementation strategy where Dr. Lopez and her staff will work with community organizations (such as churches and barber shops) to create and share informational videos and brochures that address potential concerns about SGLT2is and summarize the benefits of SGLT2is for patients. The implementation scientist works with their healthcare system to identify a ‘control’ clinic so that they can compare this combined strategy with the current standard of practice.

During the trial, Dr. Lopez and team decide to use the Exploration, Preparation, Implementation and Sustainment (EPIS) framework (i.e., a process framework) to assess how factors may have differential influence over the course of implementation of SGLT2is in these clinics.⁵⁴ To make her project more feasible, the team chooses to focus on evaluating 1) the degree of uptake of SGLT2i use among all patients and Black patients and 2) the acceptability of both the provider-facing strategy of ‘audit and provide feedback’ and the patient-facing strategy of targeted community engagement (i.e., implementation outcomes).

In this example, Dr. Lopez and her team will have partnered with an implementation science research team to 1) conduct a pre-implementation evaluation to understand the reasons for low and inequitable SGLT2i use, 2) leverage a health equity conceptual framework (determinant framework) and EPIS (process and evaluation framework) to characterize contextual factors and measure outcomes, and 3) conduct a hybrid implementation-effectiveness type 3 trial focused on understanding what strategies can equitably enhance SGLT2i use among all patients (with a focus on Black patients) in their community while simultaneously measuring the effectiveness of SGLT2i use.

Example 2: Enhancing equitable access to home dialysis for people with kidney failure

This example leverages the real-life experience of YR (an author of this paper) - an early career implementation scientist and nephrologist dedicated to understanding and addressing disparities in home dialysis use. His team began with pre-implementation evaluation to understand contextual factors that influence home dialysis use. As the first step of pre-implementation evaluation, the team created an overarching conceptual framework to guide implementation science research in home dialysis. Through literature review, they identified and integrated two conceptual models to create HOME-R: a HOME dialysis conceptual model for implementation Research (Figure 1, Panel B).55 HOME-R uses constructs from two frameworks: 1) the Systems Engineering Initiative for Patient Safety 3.0 (SEIPS 3.0)56 and 2) the Equity-based framework for Implementation Research (EquIR).53

Briefly, HOME-R uses SEIPS 3.0 to define five phases of the patient journey to home dialysis: referral to home dialysis, education to decide whether to pursue home dialysis, training to learn how to do home dialysis, initiation of home dialysis, and maintenance of home dialysis. At each of these five phases, patients interact with system elements—i.e., contextual factors such as providers, care partners, the dialysis machine and supplies, and the environment (e.g., the home or the home dialysis clinic)—all of which can serve as barriers or facilitators to home dialysis use. HOME-R also uses EquIR to identify and evaluate how social determinants of health (e.g., race, ethnicity, housing, employment) modify the influence of system elements on each phase of the patient journey to home dialysis.

The team then leveraged the HOME-R model to identify barriers and facilitators across the journey to home dialysis, conducting a national survey of patients and providers to identify major barriers to home dialysis (the IM-HOME study).55 Here, the team mapped major barriers onto the phases of the patient journey and key system elements from HOME-R to identify strategies that address multiple system elements. The team then applied HOME-R to an ongoing study, focused on understanding why home dialysis care delivery varies within the Department of Veterans Affairs. Specifically, the team conducted site visits at multiple home dialysis clinics across the country where they collected data through in-depth observations and interviews of providers, patients, and care partners. They characterized barriers to peritoneal dialysis uptake along the journey to home dialysis with the intent to apply these findings to identify implementation strategies to expand home dialysis use. At each step, the team mapped key concepts from HOME-R to each form of data collection to ensure the study captured contextual factors relevant to the patient journey, system elements, and social determinants that influence home dialysis use (see Figure 1, panel C).Through these studies, the team developed a nuanced understanding of barriers and facilitators to home dialysis, which they leveraged to identify peer support as a promising strategy to expand access to peritoneal dialysis. As an early step towards addressing disparities in home dialysis use, they plan to measure equitable reach of the peer support program as an implementation outcome (using RE-AIM, an evaluation framework),57 which will help the team understand what proportion of eligible Black Veterans with advanced CKD will receive peer support, and how that proportion compares to non-Black Veterans (Table 3).

The above examples spotlight various key concepts of implementation science but are not exhaustive. Rather, they serve as primers that outline practical required steps to incorporate implementation science and health equity to improve kidney care delivery.12,13,44,51–53,57,58

Conclusion

With recent innovations in nephrology, there is a need to rigorously design and study implementation strategies to improve equitable uptake of new and existing practices. Implementation science offers the opportunity to avoid widening disparities within nephrology but requires intentional efforts to build a workforce of implementation scientists in nephrology who can study the design and execution of these strategies. This Perspective can guide future researchers through concrete case studies on how to leverage equity-focused implementation science frameworks—such as those that incorporate EquIR or the Health Equity Implementation Framework—to improve outcomes for all patients with kidney disease.