County-Level Characteristics Associated with Variation in ESKD Mortality in the United States, 2010-2018.

Background: Geographic and neighborhood-level factors, such as poverty and education, have been associated with an increased risk for incident ESKD, likelihood of receiving pre-ESKD care, and likelihood of receiving a transplant. However, few studies have examined whether these same factors are associated with ESKD mortality. In this study, we examined county-level variation in ESKD mortality and identified county-level characteristics associated with this variation. Methods: We identified 1,515,986 individuals (aged 18-84 years) initiating RRT (dialysis or transplant) between 2010 and 2018 using the United States Renal Data System. Among 2781 counties, we estimated county-level, all-cause, age-standardized mortality rates (ASMR) among patients with ESKD. We then identified county-level demographic (e.g., percent female), socioeconomic (e.g., percent unemployed), healthcare (e.g., percent without health insurance), and health behavior (e.g., percent current smokers) characteristics associated with ASMR using multivariable hierarchic linear mixed models and quantified the percentage of ASMR variation explained by county-level characteristics. Results: County-level ESKD ASMR ranged from 45 to 1022 per 1000 person-years (PY) (mean, 119 per 1000 PY). ASMRs were highest in counties located in the Tennessee Valley and Appalachia regions, and lowest in counties located in New England, the Pacific Northwest, and Southern California. In fully adjusted models, county-level characteristics significantly associated with higher ESKD mortality included a lower percentage of Black residents (-4.94 per 1000 PY), lower transplant rate (-4.08 per 1000 PY), and higher healthcare expenditures (5.21 per 1000 PY). Overall, county-level characteristics explained 19% of variation in ESKD mortality. Conclusions: Counties with high ESKD-related mortality may benefit from targeted and multilevel interventions that combine knowledge from a growing evidence base on the interplay between individual and community-level factors associated with ESKD mortality.

Non-medical barriers in access to early steps of kidney transplantation in the United States - A scoping review.

BACKGROUND: In the United States (US), barriers in access to later steps in the kidney transplantation process (i.e. waitlisting) have been well documented. Barriers in access to earlier steps (i.e. referral and evaluation) are less well described due to the lack of national surveillance data. In this review, we summarize the available literature on non-medical barriers in access to kidney transplant referral and evaluation. METHODS: Following PRISMA guidelines, we conducted a scoping review of the literature through June 3, 2021. We included all studies (quantitative and qualitative) reporting on barriers to kidney transplant referral and evaluation in the US published from 1990 onwards in English and among adult end-stage kidney disease (ESKD) patients (PROSPERO registration number: CRD42014015027). We narratively synthesized results across studies. RESULTS: We retrieved information from 33 studies published from 1990 to 2021 (reporting data between 1990 and 2018). Most studies (n = 28, 85%) described barriers among patient populations, three (9%) among provider populations, and two (6%) included both patients and providers. Key barriers were identified across multiple levels and included patient- (e.g. demographic, socioeconomic, sociocultural, and knowledge), provider- (e.g. miscommunication, staff availability, provider perceptions and attitudes), and system- (e.g. geography, distance to care, healthcare logistics) level factors. CONCLUSIONS: A multi-pronged approach (e.g. targeted and systemwide interventions, and policy change) implemented at multiple levels of the healthcare system will be necessary to reduce identified barriers in access to early kidney transplant steps. Collection of national surveillance data on these early kidney transplant steps is also needed to enhance our understanding of barriers to referral and evaluation.

Results of a Single Arm Pilot Study of a Mobile Messaging Intervention for Hookah Tobacco Cessation in Young Adults.

BACKGROUND: Hookah tobacco use is common among young adults. Unlike cigarette smoking, there is limited evidence on mobile (ie, mHealth) interventions to promote cessation. OBJECTIVES: This pilot study tested the preliminary effects of mobile messaging for cessation in young adult hookah smokers. METHODS: Young adults (N = 20) aged 18 to 30 years who smoke hookah at least monthly and have done so at least once in the past 30 days received a 6-week mHealth multimedia messaging (text and images) intervention. Message scheduling (2 days/week × 6 weeks) was based on the literature. Content was developed iteratively by the study team and focused on health harms and addictiveness of hookah. Content was individually tailored by baseline hookah use frequency, risk beliefs, and responses to interactive text messages assessing participants' hookah tobacco use behavior and beliefs to maximize impact. Engagement was assessed during the intervention, and we examined effects on risk perceptions, risk beliefs, and risk appraisals, motivation to quit, and behavior change immediately post-intervention. RESULTS: Participants responded to 11.5 (SD = 0.69) of 12 text message prompts on average, endorsed high message receptivity (M = 6.1, SD = 0.93, range = 1-7), and reported the messages were helpful (M = 8.5, SD = 1.5, range = 1-10). There were significant (P < .05) increases in risk perceptions (d's = 0.22-0.88), risk appraisals (d = 0.49), risk beliefs (d = 1.11), and motivation to quit (d = 0.97) post-intervention. Half of participants reported reducing frequency of hookah use (20%) or quitting completely (30%) by end of treatment. CONCLUSIONS: These pilot results provide preliminary support for an mHealth messaging intervention about risks of hookah tobacco for promoting cessation. Rigorously examining the efficacy of this promising intervention is warranted.