Disparities in Kidney Care: Geography, Race, and Perceived Racial Discrimination Will Garner Continued Attention

Patients’ access to specialized care before kidney failure develops varies significantly across the United States and among different racial groups. And perceived racial discrimination may have negative effects on kidney function.

Pre-ESRD nephrology care is crucial for optimizing the health of patients with this condition. How the United States and global kidney community ensure such care for the millions of people with kidney disease is crucial to stemming the disease’s growing prevalence.

One approach is to look at the adequacy of care patients receive in different parts of the country and then examine the reasons for discrepancies in care.

Brendan Lovasik of the Emory University School of Medicine and his colleagues are taking this approach. They recently looked to see whether patients across the country are receiving adequate access to kidney care.

Using a comprehensive national data set and advanced statistical modeling techniques, the researchers identified several geographic areas in the United States with significantly low rates of pre-ESRD kidney care. Dialysis facilities in the lowest quintile of pre-ESRD nephrology care were geographically clustered in several distinct areas, including San Francisco, Los Angeles, Chicago, Miami, and Baltimore, and along the corridors of the Mississippi and Ohio Rivers. Also, facilities in the lowest quintile of pre-ESRD nephrology care were 1.88 times more likely to be located in inner cities compared with those in the highest quintile. The lowest quintile facilities were 1.96 times more likely to be in high-poverty neighborhoods. The proportion of racial minorities within a neighborhood was not associated with pre-ESRD kidney care rates.

“Improved outcomes among the chronic kidney disease population depend on earlier identification of patients with kidney disease who may require ESRD treatment, as well as greater awareness of patient morbidity and mortality, quality of life, and the financial benefits of kidney transplantation over dialysis,” said Lovasik. “Our findings may help policy makers target low–pre-ESRD facilities and regions to improve access to specialty care with interventions and specific pilot programs aimed at improving patient outcomes.”

In another recent study, Guofen Yan, PhD, of the University of Virginia, and her team looked at county-level disparities in pre-ESRD care. Their analysis of black–white comparisons included 1270 counties that had 5 or more patients of each race, resulting in 346,368 patients. Their Hispanic–white analysis included 613 counties with five or more patients of each race, resulting in 224,286 patients.

The researchers found that although disparities were more likely in certain geographic areas, they existed in diverse locations and in most counties of the United States. The overall percentage of patients who received care from a nephrologist at least 12 months before ESRD was lowest in Hispanics (20.0 percent), intermediate in blacks (23.8 percent), and highest in whites (30.0 percent). Black patients’ likelihood of receiving care from a nephrologist was 10 percent to 54 percent lower than that of whites in approximately two-thirds of the counties. Hispanic patients’ likelihood of receiving a nephrologist’s care was 10 percent to 48 percent lower than that of whites in nearly all of the counties. Counties with larger disparities tended to be of lower socioeconomic status and to have fewer health care resources, and they were more likely to be located in the South and within large metropolitan areas. “Our findings indicate that efforts to improve pre-ESRD care should be implemented nationally rather than regionally,” said Yan.

Psychosocial stressors and their role in progression of kidney disease will also garner more attention in 2015.

Recent research is already leading the way.

To look at the relationship between perceived racial discrimination and kidney function decline, researchers led by Deidra Crews, MD, FASN, of Johns Hopkins University School of Medicine, studied a biracial urban population of adults with preserved kidney function in Baltimore, MD. The team assessed whether perceived racial discrimination, as measured through an adaptation of the Experience of Racial Discrimination questionnaire, was associated with kidney function decline over five years of follow-up in the Healthy Aging in Neighborhoods of Diversity across the Life Span study. A total of 1574 participants (630 whites and 944 African Americans) aged 30 to 64 years at baseline were included.

Twenty percent of individuals in the study perceived themselves to have been discriminated against “a lot” because of their race. Such individuals were more likely to be African American and to have a higher educational background, but they were more likely to be living in poverty than those who reported little to no perceived discrimination. Additionally, those who perceived “a lot” of discrimination had higher systolic blood pressure but a lower prevalence of diabetes than did those perceiving little to no discrimination.

Perceived racial discrimination—regardless of sociodemographic, lifestyle, and health factors—was linked with greater kidney function decline over five years of follow-up. When analyzed by race and sex, the link between perceived racial discrimination and kidney function decline remained only among African American women. Systolic blood pressure was responsible for 15 percent of this association.

“Perceived racial discrimination may contribute to disparities in kidney disease and might exert its effect on risk of kidney function decline through stress-related pathways,” said Crews. “This study can serve as a basis for future studies focusing on psychosocial stressors and their potential contributions to the initiation and progression of kidney disease.”

The two studies were presented at Kidney Week 2014.

Studies

Geographic Determinants of Low Pre-ESRD Nephrology Care in the United States (Abstract SA-PO849).

Racial and Ethnic Differences in Pre-ESRD Care in U.S. Counties (Abstract SA-PO857).

Association of Perceived Racial Discrimination and Kidney Function Decline among African Americans and Whites (Abstract SA-PO856).

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