DESCRIPTION (provided by applicant): End Stage Renal Disease following failure of a previously transplanted kidney (Tx-ESRD) is the fourth leading cause of ESRD. However, its contribution to the burden of ESRD has been underappreciated because national registries do not report incident and prevalent cases of Tx-ESRD as a separate category. Several unique features of Tx-ESRD may adversely affect quality of care. Pre-dialysis planning such as dialysis modality education or vascular access placement may be delayed by efforts to prolong transplant function and uncertainty about risk for transplant failure. In addition, Tx-ESRD patients are exposed to immunosuppressive medications, are subject to psychosocial stress from the loss of a transplant, and are required to transition care from transplant to dialysis providers. However, the specific barriers that Tx-ESRD patients face are poorly understood and have not been studied in a systematic way. Moreover, little is known about feasible methods to improve Tx-ESRD quality of care. We propose a mixed methods research design to address three specific aims: A) to determine the quality of care that patients with Tx-ESRD receive during the first year of dialysis; B) To determine barriers to quality of care among patients who are transitioning from transplantation to dialysis; and C) to develop potential interventions to improve the quality of care of patients transitioning from transplantation to dialysis. Aim A will involve a retrospective cohort study of 3000 patients from Ohio, Kentucky, Indiana, and Illinois. Aim B will involve a prospective cohort study of 70 greater Cleveland patients with failing kidney transplants and their providers. Aim C will present Aim A and B findings and a systematic review on transitions of care to a national panel of 95 transplant nephrologists who will use a Delphi process to develop and rank potential interventions. This innovative approach will allow us to incorporate patient, provider, and expert perspectives. As part of the proposed study, the principal investigator will also receive training in advanced statistical techniques, qualitative research methods, and intervention trials in order to become an established clinical researcher in transitions of care along the continuum of kidney disease. The results of these analyses will be an empirically informed model of the barriers to quality of care for patients with Tx-ESRD who are transitioning to dialysis as well as feasible potential interventions to improve quality of care. The proposed study will set the stage for future intervention trials designed to optimize care and outcomes for this patient population.