Differential survival selections and care-related determinants among African Americans and Hispanics versus whites with chronic kidney disease

项目摘要 这一建议代表了我们为促进NIDDK的战略计划，以消除种族和 慢性肾病（CKD），包括终末期肾病（ESRD; 5期CKD）的种族差异。 尽管在过去二十年中进行了广泛的研究，但关键的知识差距仍然存在。首先，非裔美国人 (AAs)西班牙裔的ESRD发病率仍然比非西班牙裔白人高2-3倍， 但矛盾的是，在到达终末期肾病并接受透析后，他们的生存率比白人高得多。 推测是，这种明显的生存优势与生存劣势和缺乏足够的照顾有关。 在ESRD前阶段，AAs和西班牙裔，但确认这一点受到方法学的阻碍 挑战其次，我们仍然不明白少数民族和白人之间的死亡率差异 随着疾病的发展而演变。第三，我们没有完全掌握护理过程， 可能是可以改变的，对改善结果至关重要，影响少数民族（相对于白人）的生存选择。 为了填补这些长期存在的知识空白，我们建议进行第一次事件历史分析， 国家CKD事件人群，以深入研究结果和过程中的种族/民族差异， 在CKD的整个过程中进行护理。我们的中心假设是，少数民族（AA）之间的死亡率差异 和西班牙裔）和白人在CKD的病程中具有时间依赖性，ESRD的差异是 与ESRD前的差异有关，这是由于不同的生存选择过程之间的差异， 组在我们的三个具体目标下提出的分析将检验这一假设和其他具体假设， 研究一系列因素的差异生存选择，特别是护理过程。目标1将 详细描述了在CKD的整个病程中，种族/民族死亡率差异如何演变。 目标2将研究护理过程对不同种族/民族之间生存选择的影响 组，这推动了目标1中发现的时间依赖性变化。目标3将评估无法解释的 这些差异生存选择过程中的风险。除了我们的新假设和创新 分析方法，这项研究将促进CKD研究的方法学进步，其中包括使用 1)两个国家CKD事件队列，随访时间>15年，将ESRD前和ESRD联系起来 期-用于主要分析的全国退伍军人CKD人群（> 130万），以及Medicare CKD人群（> 130万）。 人口（> 790，000），以进一步了解全国各地的护理过程;和2）先进的 统计技术，包括时间依赖的多状态生存模型和脆弱模型。本研究将 提供了新的理解，为什么AA和西班牙裔与白人之间存在差异的生存率，以及如何 这些问题都可以得到解决。我们对AA和西班牙裔美国人的实际护理过程的结果可以直接 转化为切实可行的举措，以加强对少数CKD患者的护理。基于我们团队的 鉴于我们的业绩出色，我们预计我们的努力将继续新颖、富有成效和具有高度影响力。 .

Project Summary This proposal represents our continuing efforts to contribute to NIDDK's Strategic Plan to eliminate racial and ethnic disparities in chronic kidney disease (CKD), including end-stage renal disease (ESRD; stage 5 CKD). Despite extensive research over the last two decades, critical knowledge gaps persist. First, African Americans (AAs) and Hispanics continue to have 2-3 times higher incidence of ESRD than non-Hispanic whites (whites), but paradoxically have much better survival than whites after reaching ESRD and undergoing dialysis. Speculation is that this apparent survival advantage is related to survival disadvantage and inadequate care for AAs and Hispanics during the pre-ESRD period, but confirming this has been hampered by methodological challenges. Second, we still do not understand how differences in mortality between minorities and whites evolve over time as the disease advances. And third, we do not fully grasp how processes of care, which are potentially modifiable and vital to improving outcomes, affect survival selections among minorities (vs. whites). To close these longstanding knowledge gaps, we propose to conduct the first event-history analysis of national incident CKD populations to examine in-depth racial/ethnic disparities in outcomes and processes of care over the full course of CKD. Our central hypothesis is that differences in mortality between minorities (AAs and Hispanics) and whites are time-dependent over the course of CKD, and that differences in ESRD are related to the differences in pre-ESRD, which result from differential survival-selection processes between the groups. The analyses proposed under our three Specific Aims will test this and other specific hypotheses and examine a range of factors for the differential survival selections, particularly the processes of care. Aim 1 will yield a detailed characterization of how racial/ethnic differences in mortality evolve over the full course of CKD. Aim 2 will examine the effect of processes of care on differential survival selections among racial/ethnic groups, which drives the time-dependent changes found in Aim 1. Aim 3 will assess the role of unexplained risks in these differential survival-selection processes. In addition to our novel hypotheses and innovative analytic approaches, this study will foster methodological advances in CKD research, which include the use of 1) two national incident CKD cohorts with >15 years of follow-up that connect the pre-ESRD and ESRD periods—the national veteran CKD population (>1.3 million) for primary analyses, and the Medicare CKD population (>790,000) for further understanding of processes of care across the nation; and 2) advanced statistical techniques, including time-dependent multi-state survival models and frailty models. This study will offer novel understanding of why differential survival rates among AAs and Hispanics vs. whites exist and how they can be addressed. Our results for real-world processes of care among AAs and Hispanics can be directly translated into actionable initiatives to enhance care for minority CKD patients. Building on our team's outstanding record, we anticipate that our efforts will continue to be novel, productive and highly impactful. .