The Impact of Structural Racism on Racial/Ethnic Disparities in End-Stage Kidney Disease from Healthy Population to Mortality

项目摘要 在终末期肾病的发病率和治疗方面的种族差异是有据可查的， 一致的结果，并正在形成的共识表明，这些差距很可能是 主要是结构性种族主义（SR）。非西班牙裔黑人，任何种族的西班牙裔人和美国人 印第安人或阿拉斯加原住民（AIAN）一生中患慢性肾病（CKD）的风险较高 病程; B）更有可能从CKD进展为终末期肾病（ESKD）; c）不太可能转诊 肾移植; d）不太可能获得活体供肾移植（LDKT）; e）经验较高 移植等候名单上和移植后的死亡风险;以及f）经历更高的移植后死亡率， 移植失败这一规则的主要例外是黑人和西班牙裔ESKD的存活率较高 透析患者对于所有其他结果，观察到高度相似差异的一致性 在这些完全不同的过程中，表明更深层次的机制在起作用-即，SR.评估隐藏的 在ESKD的持续差异的SR的力量，我们将分析一个非常大的健康调查， 纵向医疗保险索赔，地理空间信息和死亡率结果。我们测量SR的方法 将是多层面的，反映当地种族/民族在经济、教育、司法、政治、 和居住成果以及医疗保健的可负担性，接触，接近和质量。进而 充分反映不同的医学治疗对ESKD患者种族/民族差异的贡献 结果，我们将衡量ESKD患者的治疗随着时间的推移，然后确定最重要的治疗 种族/民族差异的轨迹。在我们的目标1分析中，我们假设非西班牙裔黑人， 西班牙裔和AIAN个体将具有更高的ESKD发展风险，并且SR将显著 解释这些差异。我们将通过分析受限的医疗保险索赔和地理空间来验证这一假设。 数据与国家健康访谈研究（NHIS; 1994年至今; N= 941，492名符合Medicare关联条件的人）相关 受访者）。在我们的目标2分析中，我们假设非西班牙裔黑人和AIAN受访者将 不太可能接受最佳治疗轨迹，而更可能接受次佳治疗轨迹 非西班牙裔白人。我们将使用序列分析技术构建治疗轨迹， 评估美国肾脏数据系统数据集中治疗轨迹的种族/民族差异 （USRDS; 1997-2018; N= 2，335，340）。在我们的目标3分析中，我们调查了种族/民族ESKD患者是否 与非西班牙裔白人相比的生存优势被SR和治疗轨迹改变。我们 假设SR和治疗轨迹都改变了ESKD患者种族/民族差异 结果，但治疗轨迹将提供最大的解释力，由于他们更接近 与患者结局的关系。我们将通过评估每个特征 统计学解释了ESKD患者死亡率的种族/民族差异。在整个研究过程中，我们 我将与两个已建立的社区咨询委员会合作，为分析、结果、 解释和具体的拟议干预措施，并完善拟议干预措施，以供今后测试 由董事会和ESKD医疗保健专业人员提供意见。

Project Summary Racial disparities in the incidence and treatment of end-stage kidney disease are well-documented and largely consistent across outcomes, and an emerging consensus indicates that these disparities are likely to be primarily driven by structural racism (SR). Non-Hispanic Black, Hispanic persons of any race, and American Indian or Alaska Natives (AIAN) are a) at higher risk of chronic kidney disease (CKD) throughout their life course; b) more likely to progress from CKD to end-stage kidney disease (ESKD); c) less likely to be referred for kidney transplantation; d) less likely to obtain a living donor kidney transplant (LDKT); e) experience higher mortality hazards on the transplant waiting list and post-transplant; and f) experience higher rates of post- transplant graft failure. The major exception to this rule is the higher survival rate of Black and Hispanic ESKD patients on dialysis. For all other outcomes, the consistency with which highly similar disparities are observed across these disparate processes suggests that deeper mechanisms are at work — i.e., SR. To assess the hidden forces of SR underlying consistent disparities in ESKD, we will analyze a very large health survey linked to longitudinal Medicare claims, geospatial information, and mortality outcomes. Our approach to measuring SR will be multidimensional, capturing local racial/ethnic inequalities in economic, educational, judicial, political, and residential outcomes as well as health care affordability, contact, proximity, and quality. Furthermore, to fully reflect the contribution of divergent medical treatments to racial/ethnic disparities in ESKD patient outcomes, we will measure ESKD patients’ treatments over time, then identify the most important treatment trajectories for racial/ethnic disparities. In our Aim 1 analysis, we hypothesize that non-Hispanic Black, Hispanic, and AIAN individuals will have higher risk of ESKD development, and that SR will significantly explain these disparities. We will test this hypothesis by analyzing restricted Medicare claims and geospatial data linked to the National Health Interview Study (NHIS; 1994-present; N=941,492 Medicare-linkage-eligible respondents). In our Aim 2 analysis, we hypothesize that non-Hispanic Black, and AIAN respondents will be less likely to receive optimal treatment trajectories and more likely to receive suboptimal treatment trajectories than non-Hispanic Whites. We will construct treatment trajectories using sequence analysis techniques, and assess racial/ethnic disparities in treatment trajectories in the United States Renal Data System dataset (USRDS; 1997-2018; N=2,335,340). In our Aim 3 analyses, we investigate whether racial/ethnic ESKD patient survival advantages compared to non-Hispanic Whites are modified by SR and treatment trajectories. We hypothesize that SR and treatment trajectories both modify racial/ethnic disparities in ESKD patient outcomes, but that treatment trajectories will offer the greatest explanatory power due to their more proximate relationship to patient outcomes. We will test this hypothesis by assessing how well each characteristic statistically explains racial/ethnic disparities in ESKD patient mortality. Throughout the research process we will work with two established community advisory boards to generate novel ideas for analyses, results interpretation, and specific proposed interventions, and refine the proposed interventions for future testing with input from the board and ESKD health care professionals.