Contextual Predictors of Hospitalization and Quality of Life among Patients on Hemodialysis

项目摘要 在美国，超过70万人患有终末期肾病（ESKD）。这个数字增加 在过去的二十年里每年减少大约两万人。一些亚组比其他亚组更有可能取得进展 从慢性肾病到ESKD。除了在慢性肾脏疾病中建立的种族和收入差异外， 疾病进展，从事高风险物质使用的人（即，具有高健康可能性，法律的， 社会或经济后果）或经历粮食不安全或住房不稳定的人也在增加 风险尽管它们与慢性肾病进展相关，但我们不知道这些影响的程度 风险因素影响血液透析开始后的患者结局，或 血液透析受其影响。这一点很重要，因为血液透析患者暴露于这些 可改变的风险因素可能特别容易受到不良结果和高成本医疗保健利用的影响。的 拟议的研究利用了世界卫生组织的健康社会决定因素委员会 （1）高风险药物使用、粮食不安全和住房 不稳定将聚集在按社会经济地位指标分层的患者亚组内;（2）这种“风险” “因素聚集”将增加血液透析患者的住院风险，降低生活质量。 因此，本研究的两个具体目标是， 社会经济地位和高风险物质的使用，粮食不安全和住房不稳定的病人， 血液透析;并审查药物使用、粮食不安全和住房之间的独立联系 住院和生活质量不稳定。研究小组将招募330名便利样本 来自同一家大型透析机构的参与者。对于目标1，参与者将完成以下措施： 独立性（年龄、性别、种族、民族、教育、收入和财政压力、职业和社区 贫困）和因变量（药物使用、粮食不安全和住房不稳定）， 分段分析。对于目标2，研究团队将利用前瞻性队列设计来量化相关性 药物使用、粮食不安全、住房不稳定和住院率之间的关系。我们将跟踪参与者 6个月，并从透析机构病历中提取住院次数。与会者还将 在入学时完成生活质量测量。我们将研究跨部门的关联， 药物使用、粮食不安全、住房不稳定和生活质量。这项研究推动了国家 护理研究所的战略目标是支持自我管理和提高患者的生活质量 患有多种慢性病ESKD患者自我管理高度复杂的治疗方案， 多种合并症。拟议的研究将加强目前支持自我管理的办法， ESKD后遗症的三级预防，通过证明健康的社会决定因素在 现有的健康行为改变或质量改进概念框架。 1

Project Summary Over 700,000 people in the United States have end-stage kidney disease (ESKD). This number has increased by approximately 20,000 each year for over 2 decades. Some subgroups are more likely than others to progress from chronic kidney disease to ESKD. In addition to established racial and income disparities in chronic kidney disease progression, people engaging in high-risk substance use (i.e. with a high likelihood of health, legal, social, or financial consequences) or experiencing food insecurity or housing instability are also at increased risk. Despite their relevance in chronic kidney disease progression, we do not know the extent to which these risk factors affect patient outcomes after initiation of hemodialysis or which subgroups among patients on hemodialysis are affected by them. This is significant because patients on hemodialysis exposed to these modifiable risk factors may be particularly vulnerable to poor outcomes and high-cost healthcare utilization. The proposed study leverages the World Health Organization’s Commission on the Social Determinants of Health framework to generate two testable hypotheses: (1) High-risk substance use, food insecurity and housing instability will cluster within patient subgroups stratified by indicators of socioeconomic position; (2) this “risk factor clustering” will increase risk of hospitalization and decrease quality of life among patients on hemodialysis. Accordingly, the two specific aims of the study are to determine associations between indicators of socioeconomic position and high-risk substance use, food insecurity, and housing instability among patients on hemodialysis; and to examine the independent associations of substance use, food insecurity and housing instability with hospitalization and quality of life. The research team will enroll a convenience sample of 330 participants from the same large dialysis organization. For Aim 1, participants will complete measures of independent (age, gender, race, ethnicity, education, income and financial strain, occupation and community poverty) and dependent variables (substance use, food insecurity and housing instability), enabling cross- sectional analyses. For Aim 2, the study team will leverage a prospective cohort design to quantify associations between substance use, food insecurity, housing instability and hospitalization rate. We will follow participants for 6 months and extract hospitalization counts from dialysis facility medical records. Participants will also complete a measure of quality of life at enrollment. We will examine cross-sectional associations between substance use, food insecurity, housing instability and quality of life. The proposed study advances the National Institute of Nursing Research’s strategic goal to support self-management and improve quality of life for patients with multiple chronic conditions. Patients with ESKD self-manage highly complex treatment regimens and have multiple comorbidities. The proposed study will enhance current approaches to support self-management and tertiary prevention of ESKD sequelae by demonstrating the relevance of social determinants of health within existing health behavior change or quality improvement conceptual frameworks. 1