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

项目概要 终末期肾病的发病率和治疗方面的种族差异有据可查，而且在很大程度上 各种结果是一致的，并且正在形成的共识表明这些差异很可能是 主要是由结构性种族主义（SR）驱动的。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) a) 一生中患慢性肾病 (CKD) 的风险较高 当然； b) 更有可能从 CKD 进展为终末期肾病 (ESKD)； c) 不太可能被转介 肾移植； d) 获得活体肾移植（LDKT）的可能性较小； e) 更高的经验 移植等待名单上和移植后的死亡风险； f) 经历更高的事后发生率 移植失败。该规则的主要例外是黑人和西班牙裔 ESKD 的存活率较高 接受透析的患者。对于所有其他结果，观察到高度相似差异的一致性 跨越这些不同的过程表明更深层次的机制正在发挥作用——即 SR。评估隐藏的 SR 的力量是 ESKD 中持续差异的基础，我们将分析一项与以下相关的大型健康调查： 纵向医疗保险索赔、地理空间信息和死亡率结果。我们衡量 SR 的方法 将是多维的，捕捉当地在经济、教育、司法、政治、 居住结果以及医疗保健负担能力、联系方式、邻近性和质量。此外，为了 充分反映不同的医疗方法对ESKD患者种族/民族差异的影响 结果，我们将衡量 ESKD 患者随时间的治疗情况，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 人群患 ESKD 的风险较高，并且 SR 会显着 解释这些差异。我们将通过分析受限医疗保险索赔和地理空间来检验这一假设 与国家健康访谈研究相关的数据（NHIS；1994 年至今；N=941,492 符合医疗保险链接资格 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，更有可能接受次优治疗轨迹 高于非西班牙裔白人。我们将使用序列分析技术构建治疗轨迹，并且 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，我们调查种族/族裔 ESKD 患者是否 与非西班牙裔白人相比，生存优势因 SR 和治疗轨迹而改变。我们 假设 SR 和治疗轨迹都改变了 ESKD 患者的种族/民族差异 结果，但治疗轨迹将提供最大的解释力，因为它们更接近 与患者结果的关系。我们将通过评估每个特征的表现来检验这个假设 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 将与两个已建立的社区咨询委员会合作，为分析和结果产生新的想法 解释和具体建议的干预措施，并完善建议的干预措施以供未来测试 听取了董事会和 ESKD 医疗保健专业人员的意见。

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.