Dialysis Chains and Access to Cadaveric Renal Transplantation Therapy

描述(由申请人提供)：透析链和获得身体肾移植治疗摘要背景。以前的研究结果和公共政策广泛关注与美国终末期肾病(ESRD)透析患者身体供体肾脏分配相关的因素。肾移植的比率因社会人口学特征而不同，但这种差异的原因尚不完全清楚。很少有人知道为什么存在这种差异，以及透析设备链状态和患者病例组合之间的相互作用，特别是种族，是否可以进一步解释获得肾移植治疗(RTT)的差异。使用联邦医疗保险计划的数据和与器官采购和移植网络(OPTN)肾脏等待名单文件的匹配，我们将应用多水平回归模型来回答以下两个研究问题：研究问题。我们提出了两个研究问题：设施链状态对RTT访问是否存在独立(直接)影响？有待检验的假设：在控制了设施特征和患者病例组合后，链状态与患者获得RTT的机会独立相关。黑人、西班牙裔、妇女和老年人的RTT比率较低，能否进一步解释透析机构连锁地位的差异？需要检验的假设是：链状态是另一个重要的解释因素，解释了以前记录的患者年龄、性别、种族和民族在获得RTT方面的差异。研究设计。这项分析将采用回顾队列设计的方法，将血液透析患者及其提供者分为两个主要阶段：1)参加Medicare ESRD计划后的3个月基准期，在此期间将获得所有患者的基线特征；2)7年的随访期，跟踪RTT等待名单上的参与者、RTT程序、死亡和审查事件。这项研究有两个分析，每个分析都有不同的结果衡量标准。分析一：在7年的随访期内被列入OPTN身体肾移植等待名单。关于等待名单日期的数据将从USRDS UNOS文件中获得；分析II：自等待名单以来到第一次身体移植的时间，衡量的是患者在等待名单上活跃的总天数。尽管一再努力缩小RTT方面的现有差距，但这一领域的改进有限，这表明我们目前对基本机制的理解是有限的和不完整的。我们建议研究一个创新的新因素-链状态在获得RTT中的作用。此外，鉴于关于如何改善这一治疗领域的机会和公平的尖刻辩论，特别是在种族差异方面，这些连锁机构可能发挥的作用似乎至关重要，迄今尚未对其进行审查。实现研究目标将为研究机构类型与RTT之间的关系提供重要的见解，帮助临床医生和政策制定者实现更公平地获得RTT，并最终改善美国终末期肾病患者的护理和预后。最后，这项研究与2010年健康人目标一致：慢性肾脏疾病目标：减少肾移植患者种族和性别差异的目标。

DESCRIPTION (provided by applicant): Dialysis Chains and Access to Cadaveric Renal Transplantation Therapy Abstract Background. Previous research findings and public policy have focused extensively on the factors related to allocation of cadaveric donor kidneys in the U.S. among dialysis patients suffering from End Stage Renal Disease (ESRD). Kidney transplantation rates differ by sociodemographic characteristics, yet the reasons for this variation are not fully understood. Little is known about why such disparities exist and whether the interplay between dialysis facility chain status and patient case-mix, especially race, can further explain the variation in access to renal transplant therapy (RTT). Using Medicare program data and matching to Organ Procurement and Transplantation Network (OPTN) Kidney Wait List files, we will apply multilevel regression models to answer the following two research questions: Research Questions. We propose two research questions: Is there an independent (direct) effect of facility chain status on access to RTT? The hypothesis to be tested: Chain status is independently associated with patient access to RTT, after controlling for facility characteristics and patient case-mix. Can the lower RTT rates for Blacks, Hispanics, women and elderly be further explained by differences in a dialysis facility's chain status? The hypothesis to be tested: Chain status is another important explanatory factor accounting for the previously documented disparities in access to RTT by patient age, sex, race, and ethnicity. Study Design. This analysis will use a retrospective cohort design of incident hemodialysis patients and their providers with two main phases: 1) a 3-month baseline period following enrollment in the Medicare ESRD program, during which time all patient baseline characteristics will be obtained; and 2) a 7-year follow-up period that tracks the participants on the RTT wait- list, RTT procedures, death and censoring events. The study has two analyses, each with a different outcome measure. Analysis I: placement on the OPTN cadaveric kidney transplant waiting list during the 7-year follow-up period. Data on date of wait-listing will be obtained from the USRDS UNOS file; and Analysis II: time to 1st cadaveric transplantation since wait-listed, measured as the total number of days that a patient was active on the wait list Significance. Despite repeated attempts to reduce existing disparities in RTT, there have been limited improvements in this area, suggesting that our current understanding of the underlying mechanisms is limited and incomplete. We propose to examine an innovative new factor - the role of chain status - in access to RTT. Furthermore, given the vitriolic and ongoing debate on ways to improve access and equity in this treatment area, particularly in terms of racial differences, the role that the chains might play appears crucial and has to date not been examined. Achieving study objectives will provide important insights on the relationship between type of facility and RTT, aid clinicians and policy makers in achieving a more equitable access to RTT, and eventually improve care and outcomes of ESRD patients in the U.S. Finally, this study is consistent with Healthy People 2010 Objectives: Chronic Kidney Disease goals of decreasing racial and gender disparities in kidney transplantation rates.