Multilevel Intervention Strategies to Transform Kidney Care and Improve Pursuit of Transplant in an Integrated Healthcare Delivery System

项目总结 大约15%的美国人患有慢性肾脏疾病，大约70万名患者患有全肾 衰竭也称为终末期肾病(ESKD)。活体供肾是治疗ESKD的最佳方法 移植(LDKT)，然后是已故供者肾移植(DDKT)；然而， 护理仍然是持续的透析，与LDKT和DDKT相比，这种治疗的临床结果较差。最好的 医疗保险和医疗补助服务中心(CMS)建议的改变肾脏护理的做法， 美国肾脏学会(ASN)和2019年促进美国肾脏健康的行政命令 倡议包括及早发现肾脏迅速恶化的患者，将移植作为一种 潜在的治疗选择越早，最好是在他们的肾脏衰竭之前，就改善了健康知识的传播 移植教育工具，通常通过数字技术或mHealth，并通过帮助提高LDKT率 患者找到活着的捐赠者或激励其他人捐献。患者、支持网络、临床医生的障碍 社会生态模式的系统层面仍然存在，包括对高危患者的识别不力， 临床医生没有足够的时间来讨论移植，缺乏移植知识，不愿或没有足够的支持 要求活着的捐赠者，以及脱离工作的朋友和亲戚，其中一些人可能还活着 捐赠者。虽然正在进行广泛的政策和干预努力，但没有一个取得显著增长。 在追求和接受移植，特别是LDKT率。2017年，凯撒永久南加州 为24,000名CKD患者提供服务的综合护理系统(KPSC)与移植研究和 休斯顿卫理公会研究院(HMRI)教育中心(TREC)和J.C.Walter Jr.移植中心 休斯顿卫理公会医院(HMH)启动了一项转变CKD和ESKD护理的多年计划。我们现在 建议进行一项新的多水平干预的务实阶梯楔形整群随机试验 改善CKD和ESKD护理，提高移植比率，减少差距。一个创新的组成部分， 多级干预是一种最先进的技术支持的Grove Kidney Health mHealth应用程序， 与患者合作开发，以吸引患者、家庭成员和潜在的活体捐赠者 提高他们的CKD知识，查看移植成功案例，并寻求肾脏相关支持以追求 移植，包括学习如何找到活着的捐赠者。我们还寻求在不同的社会- 生态水平，特别是影响不同环境和不同环境之间有效性差异的因素 已知服务不足的患者亚群减少了移植机会，并建立了实施工具来 增加获得和争取在大型综合保健系统内进行移植的机会，包括类似的系统 (商业、学术、安全网)遍布美国。

PROJECT SUMMARY Approximately 15% of the U.S. population has chronic kidney disease, and ~700,000 patients are in full kidney failure also called end-stage kidney disease (ESKD). The optimal treatment for ESKD is living donor kidney transplantation (LDKT), followed by deceased donor kidney transplantation (DDKT); however, the standard of care continues to be ongoing dialysis, which has poor clinical outcomes in comparison to LDKT and DDKT. Best practices to transform kidney care recommended by the Centers for Medicare and Medicaid Services (CMS), the American Society of Nephrology (ASN) and the 2019 Executive Order Advancing American Kidney Health Initiative include earlier detection of patients whose kidneys are deteriorating rapidly, introducing transplant as a potential treatment option earlier, optimally before their kidneys fail, improved dissemination of health literate transplant education tools, often through digital technology or mHealth, and increasing LDKT rates by helping patients locate living donors or motivating others to donate. Barriers at the patient-, support network-, clinician- and system-levels of the Socio-Ecological Model persist, including poor identification of high-risk patients, insufficient clinician time to discuss transplant, poor transplant knowledge, reluctance or insufficient support to ask living donors to donate, and disengaged friends and relatives, some of whom who might become living donors. While extensive policy and intervention efforts are underway, none have achieved significant increases in pursuit and receipt of transplant, especially LDKT rates. In 2017, Kaiser Permanente Southern California (KPSC), an integrated care system serving 24,000 CKD patients, partnered with the Transplant Research and Education Center (TREC) at Houston Methodist Research Institute (HMRI) and J.C. Walter Jr. Transplant Center Houston Methodist Hospital (HMH) to launch a multi-year plan for transforming CKD and ESKD care. We now propose to conduct a pragmatic stepped wedge cluster randomized trial of a novel multilevel intervention to improve CKD and ESKD care, improve transplant rates and reduce disparities. One innovative component of the multilevel intervention is a state-of-the-art technology-supported Grove Kidney Health mHealth application, developed in partnership with patients, to engage patients, family members, and potential living donors to improve their CKD knowledge, view transplant success stories, and seek kidney-related support to pursue transplant, including learning how to find living donors. We also seek to identify moderators at various socio- ecological levels, especially factors influencing variations in effectiveness across different settings and among underserved patient subgroups known to have reduced access to transplant and build implementation tools to increase access to and pursuit of transplant within large integrated health systems including comparable systems (commercial, academic, safety net) across the U.S.