Addressing social adversity to improve outcomes among children undergoing liver transplant: the role for a health advocate on the transplant team

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PROJECT SUMMARY . Pediatric liver transplantation is a life-saving procedure for children with end-stage liver disease, yet long-term outcomes remain sub-optimal. Children facing social adversity, and those from socioeconomically deprived backgrounds have increased risk of graft failure and death following transplant. Disparities in post-transplant outcomes are well-known, yet the field has thus far been unable to overcome them. In contrast, pediatric primary care is rapidly evolving to develop assessment of specific social risk factors and integrate efficacious interventions to address material economic hardships (e.g., food insecurity), poor health literacy, caregiver mental health, social isolation, and neighborhood environment. One potential strategy, utilized in other fields, is to incorporate Health Advocates (team members who help patients/families address social risks) into the clinical team. To adapt a Health Advocate intervention to the needs of children undergoing liver transplantation, a more nuanced understanding of which children are at highest risk, and how a health advocate could integrate within the transplant team are needed. To that end, this study will leverage Dr. Wadhwani’s ongoing KL2 funded, multi-center prospective cohort (SOCIAL-Tx) across 8 U.S. transplant centers to achieve the following Aims: (1) Characterize the association between social risks at the time of transplant with adverse outcomes at 1 and 3 years after transplant; (2) Use multi-stakeholder qualitative interviews (patients/families, physicians, nurses, social workers) to characterize barriers and facilitators to optimal transplant care for patients/families with social risks; (3) Assess feasibility of integrating a health advocate into a liver transplant team and pilot a single-center study exploring whether targeted social support improves post-transplant outcomes. These Aims will provide the necessary preliminary data for a future clustered, pragmatic multi-center RCT testing this Health Advocate intervention. Dr. Wadhwani is an Assistant Professor of Pediatrics at the University of California, San Francisco. Building upon a strong foundation of research support, this K23 award will establish him as an independent health services researcher pioneering research at the intersection of pediatric hepatology, transplantation, and social determinants of health. Under the direct supervision of a multidisciplinary team of leaders in liver transplant/multi-center cohort building (Jennifer Lai), pediatric hepatology, and multi-center clinical trial design (John Bucuvalas), social care integration into health systems (Laura Gottlieb), and qualitative and implementation science methods (Courtney Lyles), Dr. Wadhwani will execute a detailed career development plan to achieve 4 training goals: (1) Pioneer a research niche integrating social and medical care for children undergoing liver transplantation, (2) Develop expertise in social adversity measurement and assessment, (3) Acquire skills necessary to develop, test, and implement health system interventions (e.g., multi-center prospective mixed-methodology, survey methods, in-depth interviewing, and ethnography), and (4) Develop skills in multi-center study design.