Dialysis Chains and Access to Cadaveric Renal Transplantation Therapy

描述（由申请人提供）：透析链和获得尸体肾移植治疗先前的研究结果和公共政策广泛关注与美国终末期肾病（ESRD）透析患者尸体供体肾脏分配相关的因素。肾移植率因社会人口特征而异，但造成这种差异的原因尚不完全清楚。关于为什么存在这种差异，以及透析设施链状态和患者病例组合（特别是种族）之间的相互作用是否可以进一步解释肾移植治疗（RTT）可及性的差异，我们知之甚少。使用医疗保险计划数据并匹配器官采购和移植网络（OPTN）肾脏等待列表文件，我们将应用多水平回归模型来回答以下两个研究问题：我们提出了两个研究问题：设施链状态是否对RTT的获取有独立（直接）的影响？待检验的假设：在控制了设施特征和患者病例组合后，链状态与患者获得RTT独立相关。黑人、西班牙裔、妇女和老年人较低的RTT率是否可以进一步解释为透析设施连锁状态的差异？有待检验的假设：链条状态是另一个重要的解释因素，解释了先前记录的患者年龄、性别、种族和民族在获得RTT方面的差异。研究设计。本分析将采用回顾性队列设计，对突发血透患者及其提供者进行两个主要阶段的研究：1)在加入Medicare ESRD项目后的3个月基线期，在此期间将获得患者的所有基线特征；2)为期7年的随访期，追踪RTT等待名单、RTT程序、死亡和审查事件的参与者。这项研究有两项分析，每项分析都有不同的结果衡量标准。分析一：在7年随访期间，在OPTN尸体肾移植等候名单上的位置。等待名单日期的数据将从USRDS UNOS文件中获取；分析二：从等待名单到第一次尸体移植的时间，以患者在等待名单上活跃的总天数来衡量。尽管多次尝试减少RTT中存在的差异，但这一领域的改进有限，这表明我们目前对潜在机制的理解是有限和不完整的。我们建议研究一个创新的新因素——链条地位在RTT获取中的作用。此外，考虑到如何改善这一治疗领域的获取和公平，特别是在种族差异方面，激烈而持续的辩论，链条可能发挥的作用似乎至关重要，迄今尚未得到审查。研究目标的实现将对医院类型和RTT之间的关系提供重要的见解，帮助临床医生和政策制定者实现更公平的RTT获取，并最终改善美国ESRD患者的护理和预后。最后，本研究与健康人2010年目标：慢性肾脏疾病目标一致，即减少肾移植率的种族和性别差异。

DESCRIPTION (provided by applicant): Dialysis Chains and Access to Cadaveric Renal Transplantation Therapy Abstract Background. Previous research findings and public policy have focused extensively on the factors related to allocation of cadaveric donor kidneys in the U.S. among dialysis patients suffering from End Stage Renal Disease (ESRD). Kidney transplantation rates differ by sociodemographic characteristics, yet the reasons for this variation are not fully understood. Little is known about why such disparities exist and whether the interplay between dialysis facility chain status and patient case-mix, especially race, can further explain the variation in access to renal transplant therapy (RTT). Using Medicare program data and matching to Organ Procurement and Transplantation Network (OPTN) Kidney Wait List files, we will apply multilevel regression models to answer the following two research questions: Research Questions. We propose two research questions: Is there an independent (direct) effect of facility chain status on access to RTT? The hypothesis to be tested: Chain status is independently associated with patient access to RTT, after controlling for facility characteristics and patient case-mix. Can the lower RTT rates for Blacks, Hispanics, women and elderly be further explained by differences in a dialysis facility's chain status? The hypothesis to be tested: Chain status is another important explanatory factor accounting for the previously documented disparities in access to RTT by patient age, sex, race, and ethnicity. Study Design. This analysis will use a retrospective cohort design of incident hemodialysis patients and their providers with two main phases: 1) a 3-month baseline period following enrollment in the Medicare ESRD program, during which time all patient baseline characteristics will be obtained; and 2) a 7-year follow-up period that tracks the participants on the RTT wait- list, RTT procedures, death and censoring events. The study has two analyses, each with a different outcome measure. Analysis I: placement on the OPTN cadaveric kidney transplant waiting list during the 7-year follow-up period. Data on date of wait-listing will be obtained from the USRDS UNOS file; and Analysis II: time to 1st cadaveric transplantation since wait-listed, measured as the total number of days that a patient was active on the wait list Significance. Despite repeated attempts to reduce existing disparities in RTT, there have been limited improvements in this area, suggesting that our current understanding of the underlying mechanisms is limited and incomplete. We propose to examine an innovative new factor - the role of chain status - in access to RTT. Furthermore, given the vitriolic and ongoing debate on ways to improve access and equity in this treatment area, particularly in terms of racial differences, the role that the chains might play appears crucial and has to date not been examined. Achieving study objectives will provide important insights on the relationship between type of facility and RTT, aid clinicians and policy makers in achieving a more equitable access to RTT, and eventually improve care and outcomes of ESRD patients in the U.S. Finally, this study is consistent with Healthy People 2010 Objectives: Chronic Kidney Disease goals of decreasing racial and gender disparities in kidney transplantation rates. PUBLIC HEALTH RELEVANCE: Dialysis Chains and Access to Cadaveric Renal Transplantation Therapy Study Narrative Previous research findings and public policy have focused extensively on the factors related to allocation of cadaveric donor kidneys in the U.S. among dialysis patients suffering from End Stage Renal Disease (ESRD). Kidney transplantation rates differ by sociodemographic characteristics, yet the reasons for this variation are not fully understood. Little is known about why such disparities exist and whether the interplay between dialysis facility chain status and patient case-mix, especially race, can further explain the variation in access to renal transplant therapy (RTT). This study will determine the proportion of dialysis patients placed on the Wait List and the median time for a first cadaveric kidney transplant based on chain status of the patient's dialysis facility. This study will extend research on variation of access to RTT by examining the role of chain status thereby identifying a potentially new and modifiable factor. Achieving study objectives will provide important insights on the relationship between type of facility and RTT, aid clinicians and policy makers in achieving a more equitable access to RTT, and eventually improve care and outcomes of ESRD patients in the U.S. This study is consistent with Healthy People 2010 Objectives: Chronic Kidney Disease goals of decreasing racial and gender disparities in kidney transplantation rates.