Mitigating the Effects of Structural Racism on Chronic Kidney Disease Disparities among African Americans

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ABSTRACT Racial disparities in advanced chronic kidney disease (CKD) treatment, care, and patient outcomes are profound, persistent, and pervasive. Despite a large volume of studies linking structural racism to a range of health outcomes, only recently has there been a surge in attention to the role of racism in driving the well- documented inequities in CKD. Effective CKD treatment and care can improve quality of life, reduce the need for deceased donor transplant, decrease the likelihood of allograft failure, and improve long-term patient survival; yet racial disparities exist at each point along this pathway of care due to structural racism. The Collaborative Chronic Care Model (CCM) offers a well-established, multi-level framework for organizing health systems in order to maximize outcomes among patients with chronic diseases such as CKD; however, alone, it fails to attend to the role of structural racism. We propose multi-level, multi-component interventions under a new innovative framework to motivate systemic change: we will apply the four foci of Public Health Critical Race Praxis (PHCRP), a public health framework that addresses change through an anti-racism lens, to the six components of the CCM to impact CKD care in primary care and acute care access points, nephrology, and dialysis care settings. In this manner, we propose to redesign structures within Emory Healthcare to mitigate the effect of structural racism on CKD inequities. Our long-term goal is to eliminate racial inequities in CKD progression, treatment, and care among patients within Emory Healthcare by developing a model of care that can be replicated and sustained within health systems across the country. In the development, implementation, evaluation, and dissemination of the multi- component, multi-level interventions we will rely heavily on a community-engaged approach at all stages of implementation. Our central hypothesis is that with substantial guidance from a Community Advisory Board, comprehensive systems change implemented through an anti-racism lens will improve access to all steps of care along the CKD continuum among African American patients, thereby decreasing existing racial inequities. In close collaboration with the U01 Research Coordinating Center, we propose these aims: 1. Apply PHCRP to develop multi-level, multi-component interventions that target patient & provider outcomes 2. Implement multi-level, multi-component interventions across primary care and acute care access points, nephrology, and dialysis care using the six components of the CCM and PHCRP as organizing frameworks 3. Using a quasi-experimental interrupted time series design, determine the effectiveness of the interventions on primary outcomes analyzed at the level of patients and provider type 4. Evaluate implementation and support dissemination of the multi-level, multi-component interventions using the extended RE-AIM framework to assess Reach, Effectiveness, Adoption, Implementation, and Maintenance/Sustainability from a health equity lens.