Addressing social adversity to improve outcomes among children undergoing liver transplant: the role for a health advocate on the transplant team

项目摘要。 小儿肝移植是终末期肝病儿童的一种挽救生命的手术，但长期 结果仍不理想。面临社会困境的儿童和社会经济贫困的儿童 背景技术移植失败和移植后死亡的风险增加。移植后的差异 结果是众所周知的，但实地迄今未能克服这些问题。相比之下，儿科 初级保健正在迅速发展，以发展对特定社会风险因素的评估， 解决物质经济困难的干预措施（例如，粮食不安全）、卫生知识贫乏、照顾者 心理健康、社交孤立和邻里环境。在其他领域使用的一个潜在战略是 将健康倡导者（帮助患者/家庭应对社会风险的团队成员）纳入 临床团队为了使健康倡导者干预适应接受肝移植的儿童的需要， 更细致地了解哪些儿童处于最高风险，以及健康倡导者如何整合 移植团队中的一员为此，本研究将利用Wadhwani博士正在进行的KL 2 在美国8个移植中心开展的受资助的多中心前瞻性队列研究（SOCIAL-Tx），以实现以下目标 目的：（1）描述移植时的社会风险与移植后不良结局之间的关系。 移植后1年和3年;（2）使用多利益相关者定性访谈（患者/家属，医生， 护士，社会工作者），以描述患者/家庭最佳移植护理的障碍和促进因素 （3）评估将健康倡导者纳入肝移植团队的可行性，并试点 一项单中心研究，探讨有针对性的社会支持是否能改善移植后的结果。这些目标 将为未来的集群，务实的多中心RCT测试提供必要的初步数据， 健康倡导者干预。Wadhwani博士是明尼苏达大学儿科学助理教授。 加州，旧金山弗朗西斯科。建立在强大的研究支持基础上，这个K23奖将建立 他作为一个独立的卫生服务研究员开创性的研究在儿科的交叉点， 肝病学、移植和健康的社会决定因素。在a的直接监督下 肝移植/多中心队列建设（Jennifer Lai），儿科 肝病学和多中心临床试验设计（John Bucuvalas），将社会护理纳入卫生系统 （劳拉戈特利布），定性和实施科学方法（考特尼莱尔斯），博士瓦德瓦尼将 执行详细的职业发展计划，以实现4个培训目标：（1）开拓研究利基 整合接受肝移植的儿童的社会和医疗护理，（2）发展社会专业知识， 逆境测量和评估，（3）获得发展，测试和实施健康所需的技能 系统干预（例如，多中心前瞻性混合方法，调查方法，深入 访谈和人种学），以及（4）培养多中心研究设计的技能。

PROJECT SUMMARY . Pediatric liver transplantation is a life-saving procedure for children with end-stage liver disease, yet long-term outcomes remain sub-optimal. Children facing social adversity, and those from socioeconomically deprived backgrounds have increased risk of graft failure and death following transplant. Disparities in post-transplant outcomes are well-known, yet the field has thus far been unable to overcome them. In contrast, pediatric primary care is rapidly evolving to develop assessment of specific social risk factors and integrate efficacious interventions to address material economic hardships (e.g., food insecurity), poor health literacy, caregiver mental health, social isolation, and neighborhood environment. One potential strategy, utilized in other fields, is to incorporate Health Advocates (team members who help patients/families address social risks) into the clinical team. To adapt a Health Advocate intervention to the needs of children undergoing liver transplantation, a more nuanced understanding of which children are at highest risk, and how a health advocate could integrate within the transplant team are needed. To that end, this study will leverage Dr. Wadhwani’s ongoing KL2 funded, multi-center prospective cohort (SOCIAL-Tx) across 8 U.S. transplant centers to achieve the following Aims: (1) Characterize the association between social risks at the time of transplant with adverse outcomes at 1 and 3 years after transplant; (2) Use multi-stakeholder qualitative interviews (patients/families, physicians, nurses, social workers) to characterize barriers and facilitators to optimal transplant care for patients/families with social risks; (3) Assess feasibility of integrating a health advocate into a liver transplant team and pilot a single-center study exploring whether targeted social support improves post-transplant outcomes. These Aims will provide the necessary preliminary data for a future clustered, pragmatic multi-center RCT testing this Health Advocate intervention. Dr. Wadhwani is an Assistant Professor of Pediatrics at the University of California, San Francisco. Building upon a strong foundation of research support, this K23 award will establish him as an independent health services researcher pioneering research at the intersection of pediatric hepatology, transplantation, and social determinants of health. Under the direct supervision of a multidisciplinary team of leaders in liver transplant/multi-center cohort building (Jennifer Lai), pediatric hepatology, and multi-center clinical trial design (John Bucuvalas), social care integration into health systems (Laura Gottlieb), and qualitative and implementation science methods (Courtney Lyles), Dr. Wadhwani will execute a detailed career development plan to achieve 4 training goals: (1) Pioneer a research niche integrating social and medical care for children undergoing liver transplantation, (2) Develop expertise in social adversity measurement and assessment, (3) Acquire skills necessary to develop, test, and implement health system interventions (e.g., multi-center prospective mixed-methodology, survey methods, in-depth interviewing, and ethnography), and (4) Develop skills in multi-center study design.