7. PROJECT SUMMARY/ ABSTRACT 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.

8. PROJECT NARRATIVE Despite guidelines recommending dialysis initiation via an arteriovenous vascular access (fistula or graft), 80% of US patients start hemodialysis with a catheter, leading to significant morbidity, mortality, and healthcare system expense. In other chronic illnesses, strengthening patient preparedness through education and support has been shown to improve adoption of evidence-based health recommendations and associated patient outcomes. In this randomized controlled trial among people with advanced kidney disease planning for hemodialysis, we will compare the effectiveness of three education strategies for increasing pre-dialysis arteriovenous vascular access creation and evaluate the implementation of the education strategies to inform equitable and effective translation to the non-trial setting.