NAVIGATE Kidney: A Multi-Level Intervention to Reduce Kidney Health Disparities

PROJECT SUMMARY/ ABSTRACT Latinx (gender-inclusive term; includes Hispanics, Latino/a) experience a faster progression from chronic kidney disease (CKD) to kidney failure and face a disproportionate burden of structural racism and discrimination that contribute to kidney health disparities compared to non-Latinx Whites. Latinx individuals constitute the racial and ethnic group most likely to start dialysis with a central venous catheter. Compared to non-Latinx Whites, they are less likely to start recommended kidney replacement therapy (KRT) such as home dialysis and kidney transplant. Reducing the number of individuals who start KRT with a central venous catheter is critical because it is associated with a higher risk of fatal infection, non-fatal infection, hospitalization, and mortality compared to permanent vascular access. The Advancing American Kidney Health Initiative, a 2019 Presidential executive order, aims to improve access and quality of person-centered KRT. In response, the Centers for Medicare and Medicaid Services (CMS) launched kidney value-based payment models to improve patient-centered care; however, these models do not address the structural racism that operates across socioecological levels faced by racial and ethnic minorities with CKD. Our community- partnered team assessed how structural racism operates across socioecological levels among Latinx with kidney disease and in partnership with community, developed and tested NAVIGATE-Kidney, a multi-level, language and culturally concordant community health worker (CHW) intervention for Latinx on hemodialysis. We propose to partner with our community steering committees (CSCs) in Colorado and New Mexico to refine, adapt, and test NAVIGATE-Kidney for Latinx individuals with CKD stage 4/5 (eGFR 15-29 mL/min/1.73m2) (Aim 1). We will determine the effectiveness of NAVIGATE-Kidney compared to standard care by conducting a patient-level randomized controlled trial in 448 Latinx with CKD stage 4/5 (Aim 2). Our primary hypothesis is that intervention participants will have a lower rate of central venous catheter use at KRT start (primary outcome). Our secondary hypothesis is that intervention participants will have a higher rate of optimal KRT starts (composite secondary outcome), higher patient activation, and lower decisional conflict (patient-centered outcomes). To provide the most compelling data that will address structural racism, we will assess contextual factors and implementation outcomes using the innovative PRISM (Practical Robust Implementation and Sustainable Model) framework which aligns with parameters that policymakers consider to advance health equity (Aim 3). We will conduct a comprehensive economic evaluation including a cost-effectiveness analysis of NAVIGATE-Kidney to inform policy change (Aim 4). All the proposed work will be conducted in partnership with our community steering committee and patient partners. We will set up CSC structures and procedures to ensure authentic partnership, goal-setting, shared decision-making, and language equity.