NAVIGATE Kidney: A Multi-Level Intervention to Reduce Kidney Health Disparities

项目摘要/摘要 拉丁裔(包括性别的术语；包括西班牙裔、拉丁裔/a)从慢性 肾脏疾病(CKD)到肾衰竭，并面临不成比例的结构性种族主义和 与非拉丁裔白人相比，导致肾脏健康差异的歧视。拉丁裔个体 构成最有可能开始使用中心静脉导管进行透析的种族和民族。与.相比 非拉丁裔白人，他们不太可能开始推荐的肾脏替代疗法(KRT)，如家庭 透析和肾移植。减少中心静脉行KRT的患者数量 导管至关重要，因为它与致命性感染、非致命性感染、 与永久性血管通路相比，住院和死亡率更高。前进中的美国肾脏 健康倡议是2019年总统的一项行政命令，旨在改善以人为本的机会和质量 KRT。作为回应，医疗保险和医疗补助服务中心(CMS)推出了基于肾脏价值的 改善以患者为中心的护理的支付模式；然而，这些模式没有解决结构性种族主义 这在患有慢性肾脏病的种族和少数民族面临的社会生态层面上起作用。我们的社区- 合作小组评估了结构性种族主义如何在拉丁裔中的社会生态层面上运作， 肾脏疾病，并与社区合作，开发和测试导航-肾脏，一个多层次， 语言和文化和谐的社区卫生工作者(CHW)对拉丁裔血液透析的干预。 我们建议与科罗拉多州和新墨西哥州的社区指导委员会(CSC)合作，以完善、 适应和测试导航-针对患有CKD 4/5期的Latinx患者的肾脏(EGFR 15-29毫升/分钟/1.73平方米) (目标1)。我们将通过进行一项调查来确定导航肾脏与标准护理的有效性 448例慢性肾脏病4/5期Latinx患者水平的随机对照试验(目标2)。我们的主要假设是 干预参与者在KRT Start(初级)时中心静脉导管的使用率较低 结果)。我们的第二个假设是，干预参与者将拥有更高的最佳KRT比率 开始(综合次要结果)、更高的患者活跃度和更低的决策冲突(以患者为中心 结果)。为了提供最有说服力的数据来解决结构性种族主义问题，我们将评估背景 使用创新的PRISM的因素和执行结果(切实有力的执行和 可持续模式)框架，与政策制定者考虑的促进健康的参数保持一致 公平(目标3)。我们将进行全面的经济评估，包括成本效益分析。 导航-肾以通知政策变化(目标4)。所有拟议的工作都将以伙伴关系进行。 与我们的社区指导委员会和患者合作伙伴一起。我们将建立CSC结构和程序，以 确保真正的伙伴关系、目标设定、共同决策和语言公平。

PROJECT SUMMARY/ ABSTRACT Latinx (gender-inclusive term; includes Hispanics, Latino/a) experience a faster progression from chronic kidney disease (CKD) to kidney failure and face a disproportionate burden of structural racism and discrimination that contribute to kidney health disparities compared to non-Latinx Whites. Latinx individuals constitute the racial and ethnic group most likely to start dialysis with a central venous catheter. Compared to non-Latinx Whites, they are less likely to start recommended kidney replacement therapy (KRT) such as home dialysis and kidney transplant. Reducing the number of individuals who start KRT with a central venous catheter is critical because it is associated with a higher risk of fatal infection, non-fatal infection, hospitalization, and mortality compared to permanent vascular access. The Advancing American Kidney Health Initiative, a 2019 Presidential executive order, aims to improve access and quality of person-centered KRT. In response, the Centers for Medicare and Medicaid Services (CMS) launched kidney value-based payment models to improve patient-centered care; however, these models do not address the structural racism that operates across socioecological levels faced by racial and ethnic minorities with CKD. Our community- partnered team assessed how structural racism operates across socioecological levels among Latinx with kidney disease and in partnership with community, developed and tested NAVIGATE-Kidney, a multi-level, language and culturally concordant community health worker (CHW) intervention for Latinx on hemodialysis. We propose to partner with our community steering committees (CSCs) in Colorado and New Mexico to refine, adapt, and test NAVIGATE-Kidney for Latinx individuals with CKD stage 4/5 (eGFR 15-29 mL/min/1.73m2) (Aim 1). We will determine the effectiveness of NAVIGATE-Kidney compared to standard care by conducting a patient-level randomized controlled trial in 448 Latinx with CKD stage 4/5 (Aim 2). Our primary hypothesis is that intervention participants will have a lower rate of central venous catheter use at KRT start (primary outcome). Our secondary hypothesis is that intervention participants will have a higher rate of optimal KRT starts (composite secondary outcome), higher patient activation, and lower decisional conflict (patient-centered outcomes). To provide the most compelling data that will address structural racism, we will assess contextual factors and implementation outcomes using the innovative PRISM (Practical Robust Implementation and Sustainable Model) framework which aligns with parameters that policymakers consider to advance health equity (Aim 3). We will conduct a comprehensive economic evaluation including a cost-effectiveness analysis of NAVIGATE-Kidney to inform policy change (Aim 4). All the proposed work will be conducted in partnership with our community steering committee and patient partners. We will set up CSC structures and procedures to ensure authentic partnership, goal-setting, shared decision-making, and language equity.