Reaching Equity in ACess to Home Dialysis And Re-Transplantation (REACH-DART)

实现家庭透析和再移植的公平性 (REACH-DART)

• 批准号: 10621310
• 负责人: KIRSTEN L. JOHANSEN
• 金额: $ 70.07万
• 依托单位: UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-05-15 至 2026-02-28
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10621310
• 关键词: Address; Allografting; American; Attitude; Awareness; Black Populations; Black race; Caring; Collaborations; Data; Dialysis procedure; Disease; Disparity; Disparity population; Education; Electronic Health Record; End stage renal failure; Equity; Evaluation; Exposure to; Frequencies; Future; Glomerular Filtration Rate; Goals; Health; Health Services Accessibility; Hemodialysis; Hispanic; Hispanic Populations; Home; Improve Access; Incentives; Individual; Information Systems; Insurance Carriers; Intervention; Interview; Kidney; Kidney Diseases; Kidney Transplantation; Knowledge; Link; Living Donors; Longevity; Medicaid; Medicare; Methods; Modality; Modeling; Nephrology; Not Hispanic or Latino; Organ Donor; Participant; Patient Care; Patient-Focused Outcomes; Patients; Perception; Peritoneal Dialysis; Phase; Policies; Population; Preparation; Prevalence; Privatization; Provider; Quality of life; Recording of previous events; Renal Replacement Therapy; Resistance; Risk; Structure; Surveys; System; Time; Transplant Recipients; Transplantation; United States; Variant; Visit; Waiting Lists; access disparities; cost; disease registry; electronic health data; electronic health record system; ethnic disparity; experience; falls; follow-up; frailty; graft dysfunction; graft failure; graft function; improved outcome; patient subsets; predictive modeling; racial disparity; retransplantation; social health determinants; tool; transplant centers

PROJECT ABSTRACT Kidney transplantation and home dialysis are the preferred treatment modalities for end-stage kidney disease (ESKD) given the better quality of life and lower cost of these modalities compared with in-center hemodialysis. However, in patients with graft failure, rates of preemptive re-listing for a second kidney transplant and use of peritoneal dialysis (PD) are suboptimal, especially in Black and Hispanic kidney transplant recipients (KTRs). While barriers in access to transplantation or PD in transplant-naïve patients have been attributed to lack of patient awareness of their kidney disease, late referral for subspecialty care, and inadequate education, these factors should not apply to a population that already received a kidney transplant, were likely exposed to dialysis before their first transplant, and who have access to nephrology care. Disappointingly, only half of KTRs treated with PD before their kidney transplant choose to return to this modality following graft failure, and only 15% of patients with graft failure are relisted preemptively for a second kidney transplant. The rate of PD use and relisting is particularly low in Black and Hispanic KTRs with graft failure. Identifying barriers that can be addressed to improve access of former KTRs to home dialysis and repeat transplantation will not only improve the outcomes of patients with graft failure, but also inform our understanding of the roadblocks that are present even when access to care is unlikely to be the explanatory factor. In Aim 1, we propose to model the time spent in the advanced stages of graft dysfunction and determine whether there are racial or ethnic disparities in this time, which is critical for the preparation of patients for the next phase of their disease. We will then determine if the time spent in the advanced stages of graft dysfunction is associated with access to PD or re-registration on the waitlist for a second kidney transplant. In Aim 2, we will perform semi-structured interviews with patients, dialysis providers, and transplant providers to understand their perceptions of the barriers to PD and preemptive relisting. We will then use the data derived from these qualitative interviews to develop a survey that will be administered nationally to confirm the importance of these barriers and identify strategies that can be used to surmount these barriers. In Aim 3, we will examine system-level factors that may contribute to disparities in preemptive relisting on the national waitlist and PD access, including variations in the use of objective assessments of frailty during candidacy evaluations and the frequency of follow-up contact between KTRs and their transplant center peri-graft failure. To accomplish our aims, we will leverage data from the United States Renal Data System that will be linked to Medicare, Medicaid, and Optum claims data. In a subset of patients, we will collect more granular local data from electronic health record systems to enrich these administrative data. The data from this proposal will inform the interventions, best practices, and policies that are needed to promote access to repeat transplantation and PD.

项目摘要 肾脏移植和家庭透析是终末期肾脏疾病的首选治疗方式 （ESKD）鉴于与中心血液透析相比，这些方式的生活质量和较低的成本较低。 但是，在移植失败的患者中，第二肾移植的预先重新列出和使用 腹膜透析（PD）是次优的，尤其是黑色和西班牙裔肾脏移植受者（KTRS）。 而在没有移植的患者中获得移植或PD的障碍归因于缺乏 患者对肾脏疾病的认识，较晚的专科护理和教育不足，这些 因素不应适用于已经接受过肾脏移植的人群，可能接触到 透析在第一次移植之前，并且可以获得肾脏病护理。令人失望的是，只有一半 在肾脏移植之前，用PD处理的KTR选择在移植失败后恢复这种方式，并且 第二次肾脏移植的移植失败患者中，只有15％的患者被先发。 PD的速率 黑色和西班牙裔KTR的使用和重点尤其低。确定可以 被解决以提高以前的KTR进入家庭透析的访问，重复移植不仅将 改善移植物衰竭患者的结果，但也可以告知我们对障碍的理解 现在即使获得护理也不太可能成为爆炸性因素。在AIM 1中，我们建议建模 在移植功能障碍的高级阶段所花费的时间并确定种族还是种族 这段时间的差异，这对于患者在下一阶段的疾病中至关重要。我们 然后，将确定在等级功能障碍的高级阶段所花费的时间是否与访问有关 PD或重新注册在候补名单上进行第二次肾脏移植。在AIM 2中，我们将执行半结构化 对患者，透析提供者和移植提供者的访谈，以了解他们对 PD和先发制人的障碍。然后，我们将使用这些定性访谈得出的数据 制定一项将在全国范围内进行的调查，以确认这些障碍的重要性并确定 可以用来克服这些障碍的策略。在AIM 3中，我们将研究系统级的因素 可能会导致在国家候补名单和PD访问中的先发制人的差异，包括变体 在候选评估期间对脆弱的客观评估和随访频率 KTR及其移植中心围圈衰竭之间的接触。为了实现我们的目标，我们将利用 美国肾脏数据系统的数据将链接到Medicare，Medicaid和Optum索赔 数据。在一部分患者中，我们将从电子健康记录系统中收集更多颗粒地的局部数据到 丰富这些管理数据。该提案的数据将为干预措施，最佳实践和 促进访问重复移植和PD所需的策略。