Does geographic access to care impact pediatric ESRD outcomes?

描述（由申请人提供）：卫生与公众服务部的最终规则规定，器官分配“不应基于候选人的居住地或上市地”，但根据儿童的居住地，他等待已故捐赠者肾移植的平均时间从14天到1313天不等。除了个别因素，我们不明白为什么在儿科肾移植的访问存在如此广泛的地理差异。该提案的广泛、长期目标是通过提供有针对性的干预措施来推动科学发展，以减少终末期肾病（ESRD）儿童移植机会的差异。这项研究将使用新的地理空间分析方法来表征ESRD儿童居住的地方和他们寻求移植的地方的属性，我们将深入了解这些属性如何相互作用，以影响儿科等待名单和移植的访问。使用一个创新的生态模型，结合个人，社区和机构层面的因素，我们将解开的多重因素，有助于不同的儿童获得肾移植。对于目标1，我们将使用强大的国家数据来经验性地得出每个患者居住区的社区水平的健康风险评分，并评估社区水平的健康风险是否影响移植的获得。我们假设，生活在健康的社会决定因素不太有利的社区的儿童将经历更长的时间从事件终末期肾病等待上市和移植的可能性较低。 对于目标2，我们将研究社区层面的健康风险如何与地理空间访问相互作用，以便为患有ESRD的儿童进行移植。我们假设，生活在“低风险”社区的儿童将有较短的时间从事件ESRD等待上市和增加移植的可能性，无论地理空间访问移植中心;而对于生活在“高风险”社区的儿童，较少的地理空间访问移植将构成一个重大的障碍，等待上市和移植。我们将使用患者住所邮政编码与周围移植中心的接近程度的多个指标来测量“地理空间访问”，包括旅行距离和时间。通过研究地理、社区健康和儿童肾移植获取的动态相互作用，我们将能够确定如何以及在何处实施干预措施以减少差异。这些结果将为关于如何提高所有儿童获得护理的质量、公平性和机会的国家讨论提供信息。NIH和NIDDK强调需要进行更严格的研究，以1）增加对社区对健康行为影响的理解，2）开发和测试更有效的干预措施，以减少或消除健康差异。

DESCRIPTION (provided by applicant): The Department of Health and Human Services Final Rule states that organ allocation "shall not be based on the candidate's place of residence or place of listing", yet depending on where a child lives, his median waiting time for a deceased donor kidney transplant varies from 14-1313 days. Beyond individual factors, we do not understand why such wide geographic variation in pediatric kidney transplant access exists. The broad, long- term objective of this proposal is to move science forward by informing targeted interventions to reduce disparities in transplant access for children with end-stage renal disease (ESRD). This study will use novel geospatial analytical approaches to characterize the attributes of where children with ESRD live and where they seek transplantation, and we will gain insight into how these attributes interact to influence access to pediatric wait listing and transplant. Using an innovative ecological model which incorporates individual, community-level and institutional-level factors, we will disentangle the multiple factors which contribute to differental access to kidney transplant for children. For Aim 1, we will use robust national data to empirically derive a community-level health risk score for each patient's residential neighborhood and evaluate whether community-level health risk impacts transplant access. We hypothesize that children living in communities with less favorable social determinants of health will experience longer time from incident ESRD to wait listing and lower probability of transplant. For Aim 2, we will examine how community-level health risks interact with geospatial access to transplant for children with incident ESRD. We hypothesize that children living in "lower-risk" communities will have shorter time from incident ESRD to wait listing and increased probability of transplant, regardless of geospatial access to transplant centers; whereas for children living in "higher-risk" communities, less geospatial access to transplant will pose a significant barrier to wait listing and transplant. We will measure "geospatial access" using multiple metrics of the proximity of a patient's residence ZIP code to surrounding transplant centers, including travel distance and time. By examining the dynamic interplay of geography, community-level health and pediatric kidney transplant access, we will be able to identify how and where interventions should be implemented to reduce disparities. These results will inform the national discourse on how to improve quality, equity and access to care for all children. The NIH and NIDDK have emphasized the need for more rigorous research studies to 1) increase understanding of community influences on health behaviors and 2) to develop and test more effective interventions to reduce or eliminate health disparities.