Reaching Equity in ACess to Home Dialysis And Re-Transplantation (REACH-DART)

实现家庭透析和再移植的公平性 (REACH-DART)

• 批准号: 10621310
• 负责人: KIRSTEN L. JOHANSEN
• 金额: $ 70.07万
• 依托单位: UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-05-15 至 2026-02-28
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10621310
• 关键词: Address; Allografting; American; Attitude; Awareness; Black Populations; Black race; Caring; Collaborations; Data; Dialysis procedure; Disease; Disparity; Disparity population; Education; Electronic Health Record; End stage renal failure; Equity; Evaluation; Exposure to; Frequencies; Future; Glomerular Filtration Rate; Goals; Health; Health Services Accessibility; Hemodialysis; Hispanic; Hispanic Populations; Home; Improve Access; Incentives; Individual; Information Systems; Insurance Carriers; Intervention; Interview; Kidney; Kidney Diseases; Kidney Transplantation; Knowledge; Link; Living Donors; Longevity; Medicaid; Medicare; Methods; Modality; Modeling; Nephrology; Not Hispanic or Latino; Organ Donor; Participant; Patient Care; Patient-Focused Outcomes; Patients; Perception; Peritoneal Dialysis; Phase; Policies; Population; Preparation; Prevalence; Privatization; Provider; Quality of life; Recording of previous events; Renal Replacement Therapy; Resistance; Risk; Structure; Surveys; System; Time; Transplant Recipients; Transplantation; United States; Variant; Visit; Waiting Lists; access disparities; cost; disease registry; electronic health data; electronic health record system; ethnic disparity; experience; falls; follow-up; frailty; graft dysfunction; graft failure; graft function; improved outcome; patient subsets; predictive modeling; racial disparity; retransplantation; social health determinants; tool; transplant centers

PROJECT ABSTRACT Kidney transplantation and home dialysis are the preferred treatment modalities for end-stage kidney disease (ESKD) given the better quality of life and lower cost of these modalities compared with in-center hemodialysis. However, in patients with graft failure, rates of preemptive re-listing for a second kidney transplant and use of peritoneal dialysis (PD) are suboptimal, especially in Black and Hispanic kidney transplant recipients (KTRs). While barriers in access to transplantation or PD in transplant-naïve patients have been attributed to lack of patient awareness of their kidney disease, late referral for subspecialty care, and inadequate education, these factors should not apply to a population that already received a kidney transplant, were likely exposed to dialysis before their first transplant, and who have access to nephrology care. Disappointingly, only half of KTRs treated with PD before their kidney transplant choose to return to this modality following graft failure, and only 15% of patients with graft failure are relisted preemptively for a second kidney transplant. The rate of PD use and relisting is particularly low in Black and Hispanic KTRs with graft failure. Identifying barriers that can be addressed to improve access of former KTRs to home dialysis and repeat transplantation will not only improve the outcomes of patients with graft failure, but also inform our understanding of the roadblocks that are present even when access to care is unlikely to be the explanatory factor. In Aim 1, we propose to model the time spent in the advanced stages of graft dysfunction and determine whether there are racial or ethnic disparities in this time, which is critical for the preparation of patients for the next phase of their disease. We will then determine if the time spent in the advanced stages of graft dysfunction is associated with access to PD or re-registration on the waitlist for a second kidney transplant. In Aim 2, we will perform semi-structured interviews with patients, dialysis providers, and transplant providers to understand their perceptions of the barriers to PD and preemptive relisting. We will then use the data derived from these qualitative interviews to develop a survey that will be administered nationally to confirm the importance of these barriers and identify strategies that can be used to surmount these barriers. In Aim 3, we will examine system-level factors that may contribute to disparities in preemptive relisting on the national waitlist and PD access, including variations in the use of objective assessments of frailty during candidacy evaluations and the frequency of follow-up contact between KTRs and their transplant center peri-graft failure. To accomplish our aims, we will leverage data from the United States Renal Data System that will be linked to Medicare, Medicaid, and Optum claims data. In a subset of patients, we will collect more granular local data from electronic health record systems to enrich these administrative data. The data from this proposal will inform the interventions, best practices, and policies that are needed to promote access to repeat transplantation and PD.

项目摘要 肾移植和家庭透析是终末期肾病的首选治疗方式。 (ESKD)，因为与中心血液透析相比，这些方式的生活质量更好，成本更低。 然而，在移植失败的患者中，先发制人重新列出第二次肾移植的比率和使用 腹膜透析(PD)是次要的，特别是在黑人和西班牙裔肾移植受者(KTRs)。 虽然移植后天真的患者在获得移植或PD方面的障碍被归因于缺乏 患者对他们的肾脏疾病的认识，专科护理的延迟转诊，以及教育不足，这些都是 这些因素不应适用于已经接受肾脏移植的人群，很可能暴露在 在第一次移植前进行透析的人，以及能够获得肾脏内科护理的人。令人失望的是，只有一半 肾移植前接受PD治疗的KTRS在移植失败后选择返回这种方式，并且 只有15%的移植失败患者会先发制人地再次进行第二次肾移植。帕金森病发生率 在移植失败的黑人和西班牙裔KRR中，使用和重新补充的比例特别低。确定哪些障碍可以 应解决的问题是改善前KRR获得家庭透析和重复移植的机会 改善移植物衰竭患者的预后，但也让我们了解到 即使在获得护理的机会不太可能成为解释因素的情况下也是如此。在目标1中，我们建议对 在移植物功能障碍的晚期所花费的时间，并确定是否存在种族或民族 这一时间上的差异，对于患者为下一阶段的疾病做好准备至关重要。我们 然后将确定在移植物功能障碍的晚期花费的时间是否与获得 帕金森病或在第二次肾移植的等待名单上重新登记。在目标2中，我们将执行半结构化 采访患者、透析提供者和移植提供者，了解他们对 PD的障碍和先发制人的重新启动。然后我们将使用从这些定性采访中获得的数据来 制定一项将在全国范围内实施的调查，以确认这些障碍的重要性并确定 可以用来克服这些障碍的策略。在目标3中，我们将检查系统级别的因素 可能会导致在全国等待名单和PD访问方面先发制人的差异，包括差异 在候选人资格评估期间使用对脆弱性的客观评估和后续行动的频率 KDR与其移植中心之间的接触-移植物周围失败。为了实现我们的目标，我们将利用 来自美国肾脏数据系统的数据将与Medicare、Medicaid和Optus索赔相关联 数据。在患者子集中，我们将从电子健康记录系统收集更细粒度的本地数据，以 丰富这些行政数据。此提案中的数据将为干预措施、最佳实践和 促进获得重复移植和帕金森病所需的政策。