Racial Disparity in Quality of Clinical Care in End Stage Renal Disease

描述（由申请人提供）：该提案涉及2010年健康人消除医疗保健中种族差异的目标。它还解决了最近国家对比较有效性研究的重视，以实现为所有人提供最佳护理的最终目标。终末期肾病（ESRD）在美国是一个日益增长的健康问题。在过去十年中，种族群体之间在ESRD前和ESRD护理的多个方面的不平等已经突出强调。种族差异可能发生在多个层面（个体患者、透析中心和地理区域）。解决种族不平等问题的一个根本挑战是，在采取纠正行动之前，要弄清种族不平等发生的程度，并找出每一个层次的促成因素。本申请的总体目标是在县和透析中心层面深入剖析慢性血液透析患者护理过程和临床结局中种族差异的原因。这将通过应用先进的分层（多级）统计模型来系统地检查美国透析中心和各县的各种性能指标的种族差异，并在控制患者特征的同时揭示这些差异的来源来实现。我们将研究与重要护理过程相对应的一些措施，包括贫血管理、专家（肾脏科医生、营养师）护理和ESRD治疗前的血管通路准备，以及ESRD阶段的透析剂量、贫血管理和预防性护理。我们还将研究临床结局（住院和死亡率）的种族差异，并将这些临床结局与护理指标的差异联系起来。目标1将评估ESRD前和ESRD阶段护理过程中的种族差异，以及美国各县内和各县之间的临床结局，并检查县级差异在多大程度上可归因于县特征（例如，少数民族组成、社会经济地位）。目标2将评估透析中心内和透析中心之间的种族差异，重点关注ESRD护理和临床结局，并将透析中心差异水平与中心特征（例如，所有权状态、设施规模和临床实践）。通过区域资源文件和人口普查邮政编码文件扩展的美国肾脏数据系统的扩展性为实现这些目标提供了宝贵的数据。本研究旨在加深我们对地理区域和透析中心的特征如何导致护理过程中的种族差异以及护理过程、地理区域和透析中心如何相互作用影响临床结局的理解。这项研究的结果对于制定更有针对性的医疗保健政策和干预措施至关重要，旨在消除ESRD前和ESRD护理中的种族差异。 公共卫生相关性：该提案将严格审查晚期慢性肾病患者在患者水平、透析单位水平和地理区域水平上医疗护理质量的种族差异变化。了解这种差异的来源将有助于最大限度地减少种族差异，并改善对晚期慢性肾病患者的护理。

DESCRIPTION (provided by applicant): This proposal addresses Healthy People 2010's goal of eliminating racial disparities in healthcare. It also addresses the recent national emphasis on comparative effectiveness research to achieve the eventual goal of providing optimal care to all individuals. End stage renal disease (ESRD) is a growing health concern in the United States. Inequalities in multiple aspects of pre-ESRD and ESRD care among racial groups have been prominently highlighted in the last decade. Racial disparities can occur at multiple levels (individual patient, dialysis center and geographical region). A fundamental challenge in addressing racial disparities is to unravel the levels at which racial disparities occur and to identify the contributing factors at each of these levels, before corrective actions can be taken. The overall objective of this application is to dissect the causes of racial disparities in the processes of care and clinical outcomes in depth at the county and dialysis center levels for patients on chronic hemodialysis. This will be accomplished by applying advanced hierarchical (multilevel) statistical models to systematically examine the racial disparities in various performance measures across dialysis centers and across counties in the U.S. and uncover the sources of these variations while controlling for patient characteristics. We will examine a number of measures corresponding to important processes of care, including anemia management, care by specialists (nephrologists, dietitians) and vascular access preparation prior to ESRD therapy, as well as dialysis dose, anemia management, and preventative care at the ESRD stage. We will also examine the racial disparities in clinical outcomes (hospitalization and mortality) and relate these clinical outcomes to the disparities in care indicators. Aim 1 will assess the racial disparities in the processes of care both at pre-ESRD and ESRD stages, and clinical outcomes within and across U.S. counties, and examine to what extent the county-level variation in disparity can be attributed to county characteristics (e.g., minority composition, socioeconomic status). Aim 2 will assess the racial disparities within and across dialysis centers focusing on the ESRD care and clinical outcomes, and relate the dialysis center disparity level to center characteristics (e.g., ownership status, facility size, and clinical practice). The expansiveness of the United States Renal Data System augmented with the Area Resource File and the Census Zip Code Files provides invaluable data to accomplish these Aims. This study is designed to enhance our understanding of how the characteristics of geographical region and dialysis center contribute to the racial disparity in the care processes, and how the care processes, geographic region, and dialysis center interact in influencing clinical outcomes. The results of this research are critical for the development of more focused healthcare policy and interventions aiming at eliminating racial disparity in pre- ESRD and ESRD care. PUBLIC HEALTH RELEVANCE: The proposal will critically examine the variation in racial disparity in quality of medical care at the patient level, dialysis unit level and geographical regional level in patients with advanced chronic kidney disease. Understanding the sources of this disparity would help to minimize racial disparities and improve the care of patients with advanced chronic kidney disease.