Neighborhood Accessibility as a Socio-Environmental Determinant in Kidney Transplant Health Services 公开

Abstract

Introduction: We investigated whether neighborhood accessibility to destinations by car, considered a proxy for spatial access to resources, was associated with days alive and out of the hospital (DAOH) or missed appointments after kidney transplant.

Methods: We identified a cohort of adult patients who received a kidney transplant between 2008 and 2018 from Emory University’s clinical data warehouse. Our primary outcomes were 1) DAOH at three years and 2) missed appointments per follow up time within one year. Patients’ residential addresses were geocoded and joined to the EPA Smart Location Database’s relative index of regional centrality. We used Poisson regression to estimate the associations between neighborhood accessibility, DAOH, and missed appointments, accounting for individual and ecological covariates.

Results: Our cohort included 1,926 kidney transplant recipients. The median neighborhood accessibility among patients was 0.35 out of 1 (IQR: 0.15 to 0.54). There was no association between neighborhood accessibility and DAOH at three years in the general cohort (RR: 1.00, 95% CI: 0.96 to 1.02). However, there was effect modification by suburban residence (RR: 1.11, 95% CI: 1.02, 1.21). Neighborhood accessibility was associated with missed appointments in the fully adjusted model (RR: 1.11, 95% CI: 1.01, 1.23).

Conclusions: There was no association between neighborhood accessibility and DAOH, suggesting that neighborhood accessibility does not pose a barrier for most transplant recipients. However, those living in suburban settings may face unique challenges. In contrast, lower accessibility was associated with fewer missed appointments. This may be due to the additional planning required among those in inaccessible areas or patient selection during the waitlisting process. 

Table of Contents

BACKGROUND................................................................................................................................. 1

INTRODUCTION............................................................................................................................. 1

DEFINITION OF CHRONIC KIDNEY DISEASE ................................................................................. 1

CKD AND ESKD IN THE UNITED STATES .................................................................................... 2

DEFINITION OF KIDNEY TRANSPLANTATION ................................................................................ 3

DISPARITIES IN KIDNEY TRANSPLANTATION................................................................................ 4

NEIGHBORHOOD FACTORS AND KIDNEY TRANSPLANT OUTCOMES ............................................. 5

KIDNEY TRANSPLANT AND TRANSPORTATION ............................................................................. 6

INTRODUCTION ............................................................................................................................... 8

METHODS...................................................................................................................................... 11

DATA SOURCE............................................................................................................................ 11

NEIGHBORHOOD ACCESSIBILITY ................................................................................................ 11

CALCULATION OF OUTCOMES .................................................................................................... 12

CODING OF COVARIATES............................................................................................................ 13

STATISTICAL ANALYSIS ............................................................................................................. 13

RESULTS........................................................................................................................................ 14

COHORT CHARACTERISTICS AND RELATIVE NEIGHBORHOOD ACCESSIBILITY........................... 14

DAYS ALIVE AND OUT OF THE HOSPITAL................................................................................... 15

MISSED APPOINTMENTS ............................................................................................................. 15

DISCUSSION................................................................................................................................... 16 REFERENCES................................................................................................................................. 22

TABLES ......................................................................................................................................... 26

TABLE 1 – DEMOGRAPHIC, CLINICAL, AND ECOLOGICAL CHARACTERISTICS OF COHORT ......... 26

TABLE 2 – ASSOCIATION BETWEEN ACCESSIBILITY INDEX AND DAYS ALIVE AND OUT OF THE HOSPITAL ................................................................................................................................... 30

TABLE 3 – MEAN DAYS ALIVE AND OUT OF THE HOSPITAL....................................................... 31

TABLE 4 – ASSOCIATION BETWEEN NEIGHBORHOOD ACCESSIBILITY AND MISSED APPOINTMENTS 1 YEAR AFTER TRANSPLANT ............................................................................ 32

TABLE 5 – MEAN MISSED APPOINTMENTS PER FOLLOW UP TIME (YEARS) SINCE TRANSPLANT

................................................................................................................................................... 33

TABLE 6 – MEAN APPOINTMENT COUNTS .................................................................................. 34

TABLE 7 – EFFECT MEASURE MODIFICATION OF ACCESSIBILITY INDEX ON DAYS ALIVE AND OUT OF THE HOSPITAL ............................................................................................................... 34

TABLE 8 - EFFECT MEASURE MODIFICATION OF ACCESSIBILITY INDEX ON MISSED APPOINTMENTS PER YEAR OF FOLLOW UP................................................................................. 35

FIGURES ........................................................................................................................................ 37

FIGURE 1 – MAPS OF PATIENT RESIDENCES AND ECOLOGICAL FACTORS................................... 37

SUPPLEMENTARY MATERIAL....................................................................................................... 38

SUPPLEMENTARY FIGURE 1 – DISTRIBUTION OF ACCESSIBILITY INDEX IN COHORT .................. 38

SUPPLEMENTARY FIGURE 2 – DISTRIBUTION OF DAYS ALIVE AND OUT OF THE HOSPITAL (DAOH)..................................................................................................................................... 38

SUPPLEMENTARY FIGURE 3 – DISTRIBUTION OF MISSED VISITS IN FIRST YEAR FOLLOWING TRANSPLANT.............................................................................................................................. 39 

About this Master's Thesis

Rights statement

• Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.

School	Rollins School of Public Health
Department	Environmental Health
Degree	M.S.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Epidemiology Environmental Health Health Sciences, Medicine and Surgery
关键词	health disparities kidney health services spatial epidemiology transplant outcomes
Committee Chair / Thesis Advisor	Katherine Ross-Driscoll, PhD, MPH, Emory University
Committee Members	Todd Everson, PhD, MPH, Emory University

最新修改

Primary PDF

Thumbnail	Title	Date Uploaded	Actions
	Neighborhood Accessibility as a Socio-Environmental Determinant in Kidney Transplant Health Services ()	2022-04-21 15:23:39 -0400	Press to Select an action Download

Supplemental Files

Thumbnail	Title	Date Uploaded	Actions