Does geographic access to care impact pediatric ESRD outcomes?

描述(由申请人提供)：卫生与公众服务部的最终规则规定，器官分配“不应基于候选人的居住地或登记地”，但根据儿童居住的地方，他等待已故捐赠者肾脏移植的中位数时间从14至1313天不等。除个别因素外，我们不理解为什么在儿童肾移植方面存在如此广泛的地理差异。这项建议的广泛、长期目标是通过提供有针对性的干预措施来推动科学向前发展，以减少终末期肾病(ESRD)儿童在移植机会方面的差距。这项研究将使用新的地理空间分析方法来表征患有终末期肾病的儿童在哪里生活以及他们在哪里寻求移植的属性，我们将深入了解这些属性如何相互作用，影响获得儿科等待名单和移植的机会。我们将利用一个结合了个人、社区和机构层面因素的创新生态模式，理清导致儿童获得不同肾脏移植机会的多种因素。对于目标1，我们将使用强大的国家数据来经验性地得出每个患者居住社区的社区层面的健康风险评分，并评估社区层面的健康风险是否影响移植机会。我们假设，生活在社会健康决定因素不太有利的社区的儿童从发生终末期肾病到等待登记的时间会更长，移植的概率也会更低。 对于目标2，我们将研究社区层面的健康风险如何与患有终末期肾病的儿童接受移植的地理空间相互作用。我们假设，生活在“低风险”社区的儿童从ESRD事件到等待登记的时间将更短，移植的可能性将增加，而无论地理位置如何进入移植中心；而对于生活在“高风险”社区的儿童来说，较少的地理空间获得移植将构成等待登记和移植的重大障碍。我们将使用多种衡量患者住所邮政编码与周围移植中心距离的指标来衡量“地理空间接入”，包括旅行距离和时间。通过研究地理位置、社区卫生和儿科肾脏移植机会之间的动态相互作用，我们将能够确定应该如何以及在哪里实施干预措施，以减少差异。这些结果将使全国讨论如何提高质量、公平和获得照顾所有儿童的机会。NIH和NIDDK强调需要进行更严格的研究，以1)增加对社区对健康行为影响的了解，2)开发和测试更有效的干预措施，以减少或消除健康差距。

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.