Addressing social adversity to improve outcomes among children undergoing liver transplant: the role for a health advocate on the transplant team

项目总结。 对于患有终末期肝病的儿童来说，儿童肝移植是一种挽救生命的手术，但具有长期性。 结果仍然不是最理想的。面临社会逆境的儿童和来自社会经济贫困的儿童 背景增加了移植失败和移植后死亡的风险。移植后的差异 结果是众所周知的，但该领域迄今无法克服这些结果。相比之下，儿科 初级保健正在迅速发展，以发展对特定社会风险因素的评估，并将有效的 采取干预措施解决物质经济困难(例如，粮食无保障)、卫生素养差、照顾者 心理健康、社会隔离和邻里环境。一个潜在的战略，在其他领域使用，是 将健康倡导者(帮助患者/家庭解决社会风险的团队成员)纳入 临床团队。为了使健康倡导者的干预措施适应接受肝移植的儿童的需要， 对哪些儿童风险最高，以及健康倡导者如何将 在移植团队中是需要的。为此，这项研究将利用瓦德瓦尼博士正在进行的KL2 在8个美国移植中心资助的多中心预期队列(Social-TX)，以实现以下目标 目的：(1)描述移植时的社会风险与不良后果之间的联系 移植后1年和3年；(2)使用多方利益相关者定性访谈(患者/家属、医生、 护士、社会工作者)确定患者/家庭最佳移植护理的障碍和促进者 具有社会风险；(3)评估将健康倡导者整合到肝脏移植团队的可行性，并试点 一项单中心研究，探索有针对性的社会支持是否改善移植后的结果。这些目标 将为未来的群集化、务实的多中心随机对照试验提供必要的初步数据 健康倡导者干预。Wadhwani博士是加州大学儿科学助理教授 加利福尼亚州，旧金山。在坚实的研究支持基础上，这项K23奖项将建立 作为一名独立的卫生服务研究员，他开创了儿科研究的先河 肝病、移植和健康的社会决定因素。在一名 肝脏移植/多中心队列建设的多学科领导团队(Jennifer Lai)，儿科 肝病和多中心临床试验设计(John Bucuvalas)，将社会保健纳入卫生系统 (Laura Gottlieb)，以及定性和实施科学方法(Courtney Lyles)，Wadhwani博士将 执行详细的职业发展计划以实现4个培训目标：(1)先锋研究利基 整合接受肝脏移植的儿童的社会和医疗护理，(2)发展社会专业知识 逆境测量和评估，(3)获得发展、测试和实施健康所需的技能 系统干预(例如，多中心前瞻性混合方法、调查方法、深度 访谈和民族志)，以及(4)发展多中心研究设计的技能。

PROJECT SUMMARY . Pediatric liver transplantation is a life-saving procedure for children with end-stage liver disease, yet long-term outcomes remain sub-optimal. Children facing social adversity, and those from socioeconomically deprived backgrounds have increased risk of graft failure and death following transplant. Disparities in post-transplant outcomes are well-known, yet the field has thus far been unable to overcome them. In contrast, pediatric primary care is rapidly evolving to develop assessment of specific social risk factors and integrate efficacious interventions to address material economic hardships (e.g., food insecurity), poor health literacy, caregiver mental health, social isolation, and neighborhood environment. One potential strategy, utilized in other fields, is to incorporate Health Advocates (team members who help patients/families address social risks) into the clinical team. To adapt a Health Advocate intervention to the needs of children undergoing liver transplantation, a more nuanced understanding of which children are at highest risk, and how a health advocate could integrate within the transplant team are needed. To that end, this study will leverage Dr. Wadhwani’s ongoing KL2 funded, multi-center prospective cohort (SOCIAL-Tx) across 8 U.S. transplant centers to achieve the following Aims: (1) Characterize the association between social risks at the time of transplant with adverse outcomes at 1 and 3 years after transplant; (2) Use multi-stakeholder qualitative interviews (patients/families, physicians, nurses, social workers) to characterize barriers and facilitators to optimal transplant care for patients/families with social risks; (3) Assess feasibility of integrating a health advocate into a liver transplant team and pilot a single-center study exploring whether targeted social support improves post-transplant outcomes. These Aims will provide the necessary preliminary data for a future clustered, pragmatic multi-center RCT testing this Health Advocate intervention. Dr. Wadhwani is an Assistant Professor of Pediatrics at the University of California, San Francisco. Building upon a strong foundation of research support, this K23 award will establish him as an independent health services researcher pioneering research at the intersection of pediatric hepatology, transplantation, and social determinants of health. Under the direct supervision of a multidisciplinary team of leaders in liver transplant/multi-center cohort building (Jennifer Lai), pediatric hepatology, and multi-center clinical trial design (John Bucuvalas), social care integration into health systems (Laura Gottlieb), and qualitative and implementation science methods (Courtney Lyles), Dr. Wadhwani will execute a detailed career development plan to achieve 4 training goals: (1) Pioneer a research niche integrating social and medical care for children undergoing liver transplantation, (2) Develop expertise in social adversity measurement and assessment, (3) Acquire skills necessary to develop, test, and implement health system interventions (e.g., multi-center prospective mixed-methodology, survey methods, in-depth interviewing, and ethnography), and (4) Develop skills in multi-center study design.