A place-based approach to geographic disparities in lung transplant

项目总结 虽然肺移植对于患有致命肺部疾病的患者来说是一种挽救生命的手术，但仍然有一个关键的 限制为移植后中位生存期仅为5.5年，仅为 其他器官移植类型。不幸的是，这种低存活率是由于肺部加速恶化所致。 移植后多年的功能，移植中心的做法不能完全解释，捐赠者 因素，或接受者因素。令人不安的是，不同地区的存活率也不同，差异高达39%。 根据美国的地区，我们假设那个地方，定义为社会和环境位置 对一个人有意义，影响接受者的健康，在机械论假设中，这些基于地点的因素 对肺部造成亚临床微损伤，加速移植后数年的肺功能丧失。 关于基于地点的因素如何加剧地理上不同的和 肺移植受者存活率低。在缺乏这些知识的情况下，很难准确地冒险 对接受者进行分层，并制定患者和政策层面的干预措施。为了解决这一差距，我们利用 地理信息科学，定义为测量、绘制地图和对地点的影响进行建模的框架。 目标1的范围是通过对多中心队列进行地理编码来识别个体，从而为临床决策提供信息 接受者级别的人口普查区域。这使得能够链接到高度精细的联邦数据集和广泛的社交网络 和环境健康措施，随后应用多层次模型和建立空间 聚类检测方法。这一点意义重大，因为这些结果使我们能够从现有的 早期筛查肺功能恶化或量身定做的一刀切临床方法 预防高危患者肺功能丧失的免疫抑制药物。目标2的范围是 通过绘制美国各地的差异并提高已建立的临床数据的准确性来为政策提供信息 预测模型。我们将合并单一的国家移植登记和高度有价值的联邦数据 衡量社会和环境健康因素，并测试基于地点的因素对 新的多水平模型和已建立的临床COX模型的性能。新地图，更准确 模型将是在识别和缩小地理差异以及改善 通过有针对性的资源分配取得成果。我们的长期目标是改善次优的肺移植 生存，并确保无论在哪里都能实现这一改进。这个项目很有影响力，因为我们是 第一次在肺移植方面超越我们医院的围墙来创建前所未有的全面数据 可翻译为患者和政策层面的干预措施。这项提案是对最终规则的回应 美国卫生与公众服务部要求患者地理位置应至少 在移植结果中的作用，这一任务在移植领域在过去几年中进展甚微 过去二十年，在很大程度上是由于我们的提案旨在填补的知识空白。

PROJECT SUMMARY While lung transplant is a lifesaving surgery for patients with fatal lung diseases, there remains a critical limitation as median post-transplant survival is merely 5.5 years which is only half the survival experienced by other organ transplant types. Unfortunately, this low survival is from the accelerated deterioration in lung function in the years after transplant and cannot be fully explained by transplant center practices, donor factors, or recipient factors. Troublingly, there is also disparate survival by geography which varies up to 39% depending on the region of the U.S. We hypothesize that place, defined as a social and environmental location with meaning to a person, impacts recipient health and in a mechanistic hypothesis these place-based factors cause subclinical micro-injuries to the lungs which accelerate lung function loss in the years after transplant. There is a gap in knowledge on how place-based factors exacerbate both the geographically disparate and poor survival of lung transplant recipients. In the absence of this knowledge, it is difficult to precisely risk stratify recipients and develop patient and policy level interventions. To address this gap, we leverage the Geographic Information Sciences, defined as the framework to measure, map, and model the effects of place. The scope of Aim 1 is to inform clinical decisions by geocoding a multicenter cohort to identify individual recipient level census tracts. This enables linkage to highly granular federal datasets with a wide array of social and environmental health measures followed by the application of multilevel models and established spatial cluster detection methods. This is significant as these results would enable us to pivot away from an existing one-size-fits-all clinical approach by screening earlier for worsening lung function or tailoring immunosuppression medications to prevent lung function loss for at risk patients. The scope of Aim 2 is to inform policy through mapping disparities across the U.S. and improving the accuracy of established clinical prediction models. We will merge the singular national transplant registry with highly valued federal data measuring social and environmental health factors, and test the inclusion of place-based factors on the performance of novel multilevel models and established clinical cox models. New maps and more accurate models would be a significant advance towards identifying and reducing geographic disparities and improving outcomes through targeted resource allocation. Our long-term goal is to improve the suboptimal lung transplant survival and ensure this improvement is achieved regardless of place. This project is impactful as we are the first in lung transplant to look beyond the walls of our hospitals to create unprecedented comprehensive data translatable towards patient and policy level interventions. This proposal is responsive to the Final Rule mandate by the U.S. Department of Health and Human Services that patient geography should have a minimal role in transplant outcomes, a mandate the field of transplantation has made little progress towards over the past two decades due, in large part, to gaps in knowledge that our proposal aims to fill.