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

摘要 晚期慢性肾脏病(CKD)治疗、护理和患者预后的种族差异是 深刻、持久、无处不在。尽管大量研究将结构性种族主义与一系列 关于健康结果，直到最近，人们才开始关注种族主义在推动健康发展方面的作用 记录了CKD中的不平等现象。有效的CKD治疗和护理可以提高生活质量，减少需求 对于已故供者移植，降低同种异体移植失败的可能性，并改善长期患者 然而，由于结构性种族主义，这条护理路径沿途的每一个点都存在种族差异。 协作性慢性护理模式(CCM)提供了一个完善的、多层次的组织框架 卫生系统，以最大限度地提高慢性肾脏病等慢性病患者的预后；然而， 单独而言，它没有注意到结构性种族主义的作用。我们提出了多层次、多成分的干预措施 在推动系统性变革的新创新框架下：我们将应用公共卫生的四个焦点 关键种族实践(PHCRP)，一个通过反种族主义镜头应对变化的公共卫生框架， CCM的六个组成部分，以影响初级保健和急性护理接入点的CKD护理， 肾脏病和透析护理环境。通过这种方式，我们建议重新设计埃默里内部的结构 医疗保健，以减轻结构性种族主义对CKD不平等的影响。 我们的长期目标是消除慢性肾脏病进展、治疗和患者护理中的种族不平等。 在Emory Healthcare中，通过开发一种可在健康中复制和维持的护理模式 全国各地的系统。在制定、实施、评估和传播多-- 组成部分，多层次的干预我们将在很大程度上依赖于社区参与的方法在所有阶段 实施。我们的中心假设是，在社区咨询委员会的实质性指导下， 通过反种族主义镜头实施的全面系统改革将改善获得 在非裔美国人患者中沿着CKD的连续性进行护理，从而减少现有的种族不平等。 我们与U01研究协调中心密切合作，提出以下目标： 1.应用PHCRP开发多层次、多组件的干预措施，针对患者和提供者的结果 2.在初级保健和急性护理接入点实施多层次、多组成部分的干预措施， 以CCM和PHCRP的六个组成部分为组织框架的肾脏病和透析护理 3.采用准试验性中断时间序列设计，确定干预措施的有效性 在患者和提供者类型层面上分析的主要结果 4.评价多层次、多构成部分干预措施的执行情况，并利用 扩展的RE-AIM框架，用于评估覆盖范围、有效性、采用、实施和 从健康公平的角度进行维护/可持续发展。

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.