Race and geographic area play important roles in determining whether a patient with chronic kidney disease (CKD) receives optimal care before developing kidney failure, according to a study appearing in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN). The findings suggest that policies aimed at eliminating disparities in kidney care must take these factors into account.
Timely receipt of care from a kidney specialist over the course of CKD is crucial for slowing the disease, improving survival while on long-term dialysis, and increasing the likelihood of receiving a kidney transplant. And while clinical guidelines recommend that all patients in later stages of CKD be under the care of kidney specialists, 25% to 50% of patients on dialysis in the United States had not received such care before they developed kidney failure, or end-stage renal disease (ESRD). Also, black patients with CKD are less likely to receive optimal kidney care and are more likely to develop ESRD than white patients.
Guofen Yan, PhD (University of Virginia School of Medicine) and her colleagues wondered whether geography plays any role in access to pre – ESRD care among black and white CKD patients. They analyzed information from 404,622 white and black adult patients receiving dialysis between 2005 and 2010 and residing in 3,076 counties across the United States. The counties were grouped into large metropolitan, medium/small metropolitan, suburban, and rural counties.
Among the major findings:
Fewer patients received kidney specialist care for more than 12 months before developing ESRD in large-metro (25.7%) and rural (26.9%) counties than in medium/small-metro counties (31.6%).
In all four geographic areas, black patients received less pre-ESRD care than their white counterparts. In large-metro counties, black patients were 27% less likely than whites to receive kidney specialist care for more than 12 months before developing ESRD. In rural counties, they were 16% less likely. In suburban and rural counties, black patients were 30% to 52% less likely than whites to see a dietitian before developing ESRD.
“These significant geographic differences in receiving pre-ESRD care and the substantially large racial differences in certain geographic areas highlight the complexity of the issue, and may explain in part the limited progress in improving racial disparities in kidney disease care and outcomes,” said Dr. Yan. “Our findings suggest improving receipt of key pre-ESRD care will require more refined regional characterization of health care needs,” she added.
A study of kidney failure patients found that fewer patients in large-metro and rural counties received kidney specialist care before developing kidney failure than patients in medium/small-metro counties.
In all geographic areas, black patients received less care before developing kidney failure than their white counterparts.
More than 590,000 Americans in 2010 were treated for kidney failure; more than 20 million Americans had some level of chronic kidney disease.
In an accompanying editorial, Kevin Abbott, MD, Robert Nee, MD, and Christina Yuan, MD (Walter Reed National Military Medical Center) stated that Dr. Yan and colleagues’ key finding “is that healthcare policies directed at eliminating pre-ESRD care disparities will not necessarily make ‘the crooked way straight.’ The way forward is likely to be anything but ‘straightforward’ – but there are potential investigative and intervention tools available.” For example, they pointed to the use of geospatial analysis to quantify current and future healthcare needs in high risk regions and to identify mismatches between needs and available resources. Also, telemedicine could potentially improve access to quality care to otherwise isolated communities, either rural or urban, they wrote.
Race/Ethnicity and Kidney Disease
African Americans, Hispanic Americans, Native Americans and Asian Americans are more at risk for kidney disease. This may be because these groups tend to have higher rates of diabetes and high blood pressure, the two leading causes of kidney failure. Access to healthcare and other factors may also contribute.
Numerous studies have documented the presence of racial disparities among Americans in health outcomes with respect to cardiovascular disease, infant mortality, cancer, and kidney disease. With regard to kidney diseases, these disparities are more dramatic. African, Hispanic, and Native Americans have the highest risks of end-stage renal disease (ESRD). The incidence of ESRD is four times higher in African Americans than in whites. Diseases causing chronic kidney failure, such as diabetes mellitus, hypertension, systemic lupus erythematosus, and human immunodeficiency virus-associated nephropathy, are particularly prevalent among African-American patients. In addition to the higher prevalence, the morbidity associated with kidney complications of these diseases appears worse in African-American patients. African Americans also have worse outcomes and a relatively reduced access to kidney transplantation – the best therapy for ESRD. It is highly likely that social and environmental factors play a very significant role in the persistence of these disparities. A detailed understanding of these socioeconomic and environmental factors will be critical in formulating rational public health strategies to redress these disparities.
Race and kidney disease: role of social and environmental factors.
Chike M. Nzerue, Haliu Demissochew, and J. Kevin Tucker
Study co-authors include Alfred Cheung, MD, Tom Greene, PhD (University of Utah); Keith Norris, MD (Charles R. Drew University of Medicine and Science); Alison Yu (University of Southern California); Jennie Ma, PhD, M. Norman Oliver, MD, and Wei Yu (University of Virginia School of Medicine).
Disclosures: The authors reported no financial disclosures. This work is funded by NIH/NIDDK 5R01DK084200-02. In addition, Dr. Keith Norris is supported in part by NIH grants U54MD007598, UL1TR000124, P30AG021684, and P20-MD000182.
The article, entitled “The Associations between Race and Geographic Area and Quality-of-Care Indicators in Patients Approaching ESRD,” will appear online at http://cjasn.asnjournals.org/ on March 14, 2013, doi: 10.2215/CJN.07780812.
The editorial, entitled “Making the Crooked Way Straight: Interpreting Geography and Healthcare Delivery in Chronic Kidney Disease,” will appear online at http://cjasn.asnjournals.org/ on March 14, 2013.
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