Multi-level Factors that Influence Dialysis Facilities' Assessments of Patient Suitability for Transplantation

项目总结/摘要 对于大多数终末期肾病（ESRD）患者，肾移植是最佳治疗方法。 服务不足的种族/少数民族和低收入个体的ESRD负担更大（更高） 发病率和更快的进展），但他们获得移植的机会要少得多。在患者 考虑在移植中心等待，透析设施团队执行复杂的医疗和 对患者是否适合移植进行社会心理评估，并决定是否将他们转介到移植手术 中心进行全面评估。这些转诊前评估过程在临床团队中差异很大， 已经被确定为移植下游差异的最重要的潜在驱动因素之一， 等待名单和收据。本申请的目标是NIDDK指导研究科学家发展 Award（K 01）是为了支持埃默里大学罗林斯公共卫生学院的一位助理教授， 成为一个独立的卫生服务研究人员完全具备的技能，建立了解 这些病人的评估过程，并改善他们的治疗结果。为此，这个K 01奖项将 提供临床肾脏病学、定性和调查研究方法、实施科学方面的培训 框架和赠款写作。研究的目的是加强和应用这些新的技能， 透析机构转诊前患者评估过程调查中的概念。具体而言是 K 01的研究目标是使用严格的定性和调查研究方法来阐明 认知负荷（压力、时间压力、中断）的可测量和可修改的供应商水平结构， 不确定性容忍度（对不确定性的焦虑或担忧）及其对转诊前差异的影响 在透析设施环境中进行评估。目标1将使用定性方法来探索供应商如何- 水平因子（例如，认知负荷，不确定性容忍度）和多水平背景因素（例如，设施级 标准协议、当地移植中心政策）塑造透析机构团队的转诊前流程 患者评估。目标2将制定并验证一项调查，以量化工作人员、透析设施和社区 在转诊前评估的背景下，使用调查试点和严格的改良德尔菲法 approach. Aim 3将对13个州的2000名透析机构工作人员进行调查，并使用相关数据， 患者移植评估结果（转诊、评估开始和等待），以评估工作人员如何认知 负荷和不确定性耐受与移植获得中的种族/民族和社会经济差异有关 以及透析设施和社区特征。受保护的时间、资源和指导 通过这个职业发展奖将使亚当威尔克博士成为一个独立的， 领先的研究人员，进行开创性的调查研究，促进发展， 实施多层次干预措施，消除获得移植或其他首选器官方面的障碍， 为服务不足的肾病和其他复杂慢性病患者提供治疗。

Project Summary/Abstract For most patients with end-stage renal disease (ESRD), kidney transplantation is the optimal treatment. Underserved racial/ethnic minority and low-income individuals have a greater burden of ESRD (higher incidence and more rapid progression), yet they have much poorer access to transplant. Before patients are considered for waitlisting at a transplant center, dialysis facility teams perform complex medical and psychosocial assessments of patients' suitability for transplant and decide whether to refer them to a transplant center for full evaluation. These pre-referral assessment processes, which vary widely across clinical teams, have been identified as among the most important potential drivers of downstream disparities in transplant waitlisting and receipt. The objective of this application for a NIDDK Mentored Research Scientist Development Award (K01) is to support an assistant professor at the Emory University Rollins School of Public Health to become an independent health services researcher fully equipped with the skills to build understanding of these patient assessment processes and to improve their treatment outcomes. To that end, this K01 award will provide training in clinical nephrology, qualitative and survey research methods, implementation science frameworks, and grant-writing. The research aims are designed to reinforce and apply these new skills and concepts in an investigation of dialysis facilities' pre-referral patient assessment processes. Specifically, the K01's research objective is to use rigorous qualitative and survey research methods to elucidate the measurable and modifiable provider-level constructs of cognitive load (stress, time pressure, disruptions) and uncertainty tolerance (anxiety or worry in response to uncertainty) and their impact on disparities in pre-referral assessments within their dialysis facility context. Aim 1 will use qualitative methods to explore how provider- level factors (e.g., cognitive load, uncertainty tolerance) and multi-level contextual factors (e.g., facility-level standard protocols, local transplant center policies) shape dialysis facility teams' processes for pre-referral patient assessment. Aim 2 will develop and validate a survey to quantify staff, dialysis facility, and community characteristics in the context of pre-referral assessments using a survey pilot and a rigorous modified Delphi approach. Aim 3 will conduct a survey of n≈2000 dialysis facility staff across 13 states and use linked data on patient transplant evaluation outcomes (referral, evaluation start, and waitlisting) to assess how staff cognitive load and uncertainty tolerance are related to racial/ethnic and socioeconomic disparities in transplant access as well as dialysis facility and community characteristics. The protected time, resources, and mentoring available through this career development award will enable Dr. Adam Wilk to emerge as an independent and leading researcher, conducting groundbreaking survey research and fostering the development and implementation of multi-level interventions to address barriers in access to transplant or other preferred treatments for underserved patients with kidney disease and other complex chronic conditions.