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

项目总结 飓风玛丽亚是美国现代史上最严重的自然灾害之一。据估计，玛丽亚造成了 3000人死亡，1390亿美元的岛上基础设施受损。飓风玛丽亚造成持续时间延长 停电使肾衰竭患者无法获得医疗服务。大多数肾脏病患者 失败的患者每周在门诊透析机构接受三次血液透析。玛丽亚期间进行透析的途径 在波多黎各的一些地区是有限的或根本不存在，一些患者需要前往其他设施 在岛上或美国本土接受照顾。玛丽亚可能扰乱了常规的透析护理，导致 增加死亡、住院或其他不良事件的风险。非常有必要了解 这场大规模自然灾害在脆弱人群中的后果，考虑到社会和 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 波多黎各所有透析患者的数据来自美国肾脏数据系统和定性访谈 对于服务提供者和诊所工作人员，我们的具体目标如下：1)审查以下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。我们的工作假设是 与灾难前相比，飓风玛丽亚增加了肾衰竭患者的迁出；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 流动的肾衰竭患者，玛丽亚治疗前后。我们的假设是，在玛丽亚之后， 移民到波多黎各以外的人将经历死亡率和入院人数的增加 与没有迁出波多黎各的人进行比较；以及3)检查透析提供者的策略和 减轻飓风对肾衰竭患者影响的感知障碍，并了解长期的 通过定性访谈对透析提供者组织和工作人员的任期后果。我们预计 这些访谈将提供深入的、新颖的见解，以了解提供者保持护理连续性和 避免关闭透析设施。这项建议是对FOA(PA-20-172)“长期影响”的直接回应 灾难对服务于健康差距人群的医疗保健系统的影响。这项提议是第一步 有助于更广泛地了解飓风玛丽亚对复杂人口的影响。建议数 该项目与NIMHD感兴趣的地区保持一致，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的首要目标 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 正在接受透析(自2010年以来约有14,000名患者)，具有丰富的临床和社会经济变量，使我们能够 跟踪移民模式、死亡率和住院结果，并与提供者进行定性访谈 和诊所的工作人员。我们的研究将为包括改善患者的移民在内的策略提供证据 肾功能衰竭患者在自然灾害后获得护理和健康结果的机会。

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.