Long-Term Effects of Hurricane Maria on Healthcare Delivery, Migration and Mortality Among People with Kidney Failure in Puerto Rico

项目摘要 飓风玛丽亚是美国现代史上最严重的自然灾害之一。玛丽亚造成了估计 3,000人死亡，岛上基础设施损失1390亿美元。飓风玛丽亚造成长时间的 停电使肾衰竭患者无法获得医疗服务。大多数肾病患者 透析失败者每周在门诊透析机构接受三次血液透析。Maria期间透析的使用 在波多黎各的某些地区， 在岛上或美国大陆接受治疗。玛丽亚可能扰乱了常规的透析治疗，导致 死亡、住院或其他不良事件的风险增加。有一个至关重要的需要了解 鉴于社会和经济状况， 医疗保健不平等，以及玛丽亚在岛上造成的广泛破坏。使用纵向 来自美国肾脏数据系统的波多黎各所有透析患者的数据以及 提供者和诊所工作人员，我们的具体目标如下：1）研究人口外流的长期趋势， 波多黎各的肾衰竭患者，飓风玛丽亚前后。我们的假设是 与灾前相比，飓风玛丽亚增加了肾衰竭患者的向外迁移; 2） 估计飓风玛丽亚对移民和非移民死亡率和住院率的长期影响 患有肾衰竭的移民患者，在玛丽亚之前和之后。我们的假设是跟着玛丽亚， 移民到波多黎各以外的人的死亡率和住院率将增加 与未从波多黎各迁出的人相比;以及3）检查透析提供者的策略， 减轻飓风对肾衰竭患者影响的感知障碍，并了解长期 通过定性访谈对透析提供者组织和工作人员的长期影响。我们预计 这些访谈将提供深入的，新颖的见解提供者的战略，以保持护理的连续性， 避免透析设施关闭。本提案是对FOA（PA-20-172）“长期影响”的直接回应 为健康差异人群服务的医疗保健系统的灾难。这项建议是第一步 更广泛地了解飓风玛丽亚对复杂人群的影响。拟议 该项目与NIMHD感兴趣的领域保持一致，包括美国领土，社会经济弱势群体 以及了解自然灾害对人类的长期影响这一总体目标， 健康差距人口和为他们服务的卫生保健系统。我们使用患者的纵向数据 接受透析（自2010年以来约14，000例患者），具有丰富的临床和社会经济协变量， 跟踪移民模式、死亡率和住院治疗结果，并与提供者进行定性访谈 和诊所工作人员。我们的研究将提供有关策略的证据，包括改善患者 在自然灾害后，肾衰竭患者获得护理和健康结果。

PROJECT SUMMARY Hurricane Maria was one of the worst natural disasters in modern US history. Maria caused an estimated 3,000 deaths and $139 billion in damage to the Island's infrastructure. Hurricane Maria caused prolonged electricity outages that prevented people with kidney failure from accessing care. Most patients with kidney failure receive hemodialysis at outpatient dialysis facilities three times a week. Access to dialysis during Maria was limited or non-existent in some areas in Puerto Rico, and some patients needed to travel to other facilities on the island or to the US mainland to receive care. Maria may have disrupted regular dialysis care, leading to increased risk of death, hospitalization, or other adverse events. There is a crucial need to understand the consequences of this large-scare natural disaster among this vulnerable population, given social and healthcare inequalities, and the extensive level of destruction caused by Maria on the island. Using longitudinal data for all dialysis patients in Puerto Rico from the US Renal Data System and qualitative interviews with providers and clinic staff, our specific aims are as follows: 1) Examine long-term trends in outmigration among persons with kidney failure in Puerto Rico, pre- and post-Hurricane Maria. Our working hypothesis is that Hurricane Maria increased out-migration of kidney failure patients relative to the pre-disaster period; 2) Estimate the long-term impact of Hurricane Maria on mortality and hospitalizations among migrant and non- migrant patients with kidney failure, pre- and post-Maria. Our working hypothesis is that following Maria, persons who migrated outside of Puerto Rico will experience increased mortality and hospital admissions compared to persons who did not migrate out of Puerto Rico; and 3) Examine dialysis providers' strategies and perceived barriers to mitigating the Hurricane's effects on patients with kidney failure and understand the long- term consequences for dialysis provider organizations and staff through qualitative interviews. We expect these interviews will provide in-depth, novel insights into providers' strategies to maintain continuity of care and avoid dialysis facility closures. This proposal is a direct response to the FOA (PA-20-172) “Long-Term Effects of Disasters on Health Care Systems Serving Health Disparity Populations.” This proposal is a first step towards a broader understanding of the impact of Hurricane Maria on complex populations. The proposed project aligns with the NIMHD areas of interest, including U.S. territories, socioeconomically disadvantaged populations, as well as the overarching goal of understanding the long-term effects of natural disasters on health disparity populations and the health care systems that serve them. We use longitudinal data for patients undergoing dialysis (~14,000 patients since 2010) with rich clinical and socioeconomic covariates that allow us to track migration patterns and mortality and hospitalization outcomes and qualitative interviews with providers and clinic staff. Our study will provide evidence on the strategies, including migration that improves patient access to care and health outcomes following a natural disaster among patients with kidney failure.