Grant: Tm Gr.:Embr. Diversity to Achieve Precision/Health Equity-Nutrition/Meta. Health

Chronic kidney disease affects 1 in 10 Canadians, where low kidney function over time can progress to kidney failure requiring dialysis or transplant. People with chronic kidney disease often experience other health conditions, such as diabetes and heart disease, as well as challenges when accessing health care because of the circumstances in which they are born, grow, work, and live. These non-medical factors are called 'social determinants of health' and include education, employment, housing, income, and social networks. Research has shown that people with kidney disease experience urgent health complications that lead to hospital admission 5 times more often than people without kidney disease. One in 4 of these patients will be readmitted within one month of leaving hospital. However, we do not know how their social determinants of health and differences in gender, race, income, living location, and access to health care impact their chances of needing to be readmitted. To address this problem, our team of researchers, health care providers, and people living with kidney disease first proposes to study how these factors affect a person's chances of hospital readmission. We will use a variety of research methods, including analyzing information from patients' electronic health records and conducting interviews with hospitalized patients with kidney disease and their loved ones. Next, we will use this information to create an electronic tool to help patients and their care team determine their chances of being readmitted to hospital. Lastly, in partnership with patients, health care providers, and community organizations, we will design a care strategy that involves supports and resources that are personalized for each patient to prevent future hospital readmission. In addition to promoting fair and personalized care, this project will help reduce the number of people needing to be hospitalized and reduce costs in Canadian hospitals.