Does geographic access to care impact pediatric ESRD outcomes?

描述（由申请人提供）：卫生和人类服务部最终规则规定，器官分配“不应基于候选人的居住地或上市地点”，但取决于儿童居住的地方，他等待已故捐赠者肾脏移植的中位数时间从14-1313天不等。除了个体因素外，我们不明白为什么儿童肾移植准入存在如此大的地理差异。该提案的广泛、长期目标是通过告知有针对性的干预措施来推动科学进步，以减少终末期肾病（ESRD）儿童移植可及性的差异。本研究将使用新颖的地理空间分析方法来描述ESRD儿童居住的地方和他们寻求移植的地方的属性，我们将深入了解这些属性如何相互作用以影响儿科等待名单和移植的获取。采用创新的生态模型，结合个人、社区和机构层面的因素，我们将解开导致儿童获得不同肾脏移植机会的多重因素。对于目标1，我们将使用强大的国家数据，以经验得出每个患者居住社区的社区水平健康风险评分，并评估社区水平的健康风险是否影响移植获取。我们假设，生活在健康社会决定因素较差的社区的儿童从ESRD事件到等待名单的时间较长，移植的可能性较低。

DESCRIPTION (provided by applicant): The Department of Health and Human Services Final Rule states that organ allocation "shall not be based on the candidate's place of residence or place of listing", yet depending on where a child lives, his median waiting time for a deceased donor kidney transplant varies from 14-1313 days. Beyond individual factors, we do not understand why such wide geographic variation in pediatric kidney transplant access exists. The broad, long- term objective of this proposal is to move science forward by informing targeted interventions to reduce disparities in transplant access for children with end-stage renal disease (ESRD). This study will use novel geospatial analytical approaches to characterize the attributes of where children with ESRD live and where they seek transplantation, and we will gain insight into how these attributes interact to influence access to pediatric wait listing and transplant. Using an innovative ecological model which incorporates individual, community-level and institutional-level factors, we will disentangle the multiple factors which contribute to differental access to kidney transplant for children. For Aim 1, we will use robust national data to empirically derive a community-level health risk score for each patient's residential neighborhood and evaluate whether community-level health risk impacts transplant access. We hypothesize that children living in communities with less favorable social determinants of health will experience longer time from incident ESRD to wait listing and lower probability of transplant. For Aim 2, we will examine how community-level health risks interact with geospatial access to transplant for children with incident ESRD. We hypothesize that children living in "lower-risk" communities will have shorter time from incident ESRD to wait listing and increased probability of transplant, regardless of geospatial access to transplant centers; whereas for children living in "higher-risk" communities, less geospatial access to transplant will pose a significant barrier to wait listing and transplant. We will measure "geospatial access" using multiple metrics of the proximity of a patient's residence ZIP code to surrounding transplant centers, including travel distance and time. By examining the dynamic interplay of geography, community-level health and pediatric kidney transplant access, we will be able to identify how and where interventions should be implemented to reduce disparities. These results will inform the national discourse on how to improve quality, equity and access to care for all children. The NIH and NIDDK have emphasized the need for more rigorous research studies to 1) increase understanding of community influences on health behaviors and 2) to develop and test more effective interventions to reduce or eliminate health disparities.