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

项目摘要 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，而且在很大程度上 所有结果都是一致的，一个新兴的共识表明，这些差距很可能是 主要由结构性种族主义(SR)驱动。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)一生中患慢性肾脏疾病(CKD)的风险更高 病程；b)更有可能从慢性肾脏病进展到终末期肾病(ESKD)；c)不太可能被转诊为 肾移植；d)不太可能获得活体供肾移植(LDKT)；e)体验更高 移植等待名单上的死亡危险和移植后；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 接受透析治疗的患者。对于所有其他结果，观察到高度相似的差异的一致性 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ESKD的持续差异，我们将分析一个非常大的健康调查与 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 将是多维的，捕捉到当地在经济、教育、司法、政治、 和居住结果以及卫生保健可负担性、接触、接近和质量。此外，要 充分反映不同医疗方法对ESKD患者种族/民族差异的贡献 结果，我们将随着时间的推移衡量ESKD患者的治疗，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人患ESKD的风险更高，而且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检验这一假设 与国家健康访谈研究(NHIS；1994年至今；N=941,492符合医疗保险关联资格)相关的数据 受访者)。在我们的Aim 2分析中，我们假设非西班牙裔黑人和AIAN受访者将是 接受最佳治疗轨迹的可能性较小，而接受次优治疗轨迹的可能性较大 而不是非西班牙裔白人。我们将使用序列分析技术构建治疗轨迹，以及 在美国肾脏数据系统数据集中评估治疗轨迹中的种族/民族差异 (USRDS；1997-2018；N=2,335,340)。在我们的Aim 3分析中，我们调查了种族/民族ESKD患者 与非西班牙裔白人相比，生存优势受到SR和治疗轨迹的影响。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 与患者预后的关系。我们将通过评估每个特征有多好来检验这一假设 统计学上解释了ESKD患者死亡率的种族/民族差异。在整个研究过程中，我们 将与两个现有的社区咨询委员会合作，为分析、结果产生新的想法 解释和具体的拟议干预措施，并完善拟议干预措施以供未来测试 来自董事会和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.