Disparities in Predialysis Nephrology Care Persist, Study Finds

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Recent years have brought little progress toward reducing disparities in access to predialysis nephrology care among racial/ethnic minority patients in the United States, concludes a study in JAMA Network Open.

The study included data on more than 1 million adults who initiated maintenance dialysis between 2005 and 2015, drawn from the US Renal Data System. The patients were 57.2% male; mean age was 62.4 years. Race/ethnicity was white in 54.6% of patients, Black in 27.8%, Hispanic in 14.0%, and Asian in 3.6%. Multivariable logistic regression analyses were performed to analyze trends in racial/ethnic disparities in receipt of at least 1 year of nephrology specialty care before the start of dialysis.

Overall, 31.1% of patients received at least 1 year of predialysis nephrology care. For all racial/ethnic groups, unadjusted rates of predialysis nephrology care increased between 2005–07 and 2014–15: from 30.1% to 39.5% for white, 24.5% to 32.5% for Black, 21.2% to 28.3% for Hispanic, and 26.1% to 37.1% for Asian patients.

On adjusted analysis, racial/ethnic minorities remained less likely to receive specialty care in the year before dialysis, compared to white patients. In 2005–2007, odds ratios (ORs) were 0.82 for Black, 0.67 for Hispanic, and 0.84 for Asian patients. These odds were little changed in 2014–2015: OR 0.76 for Black, 0.61 for Hispanic, and 0.90 for Asian patients. Exploratory mediation analyses suggested that racial/ethnic differences in health insurance type were more strongly associated with small reductions in racial/ethnic disparities, compared to other factors.

Among patients with end stage kidney disease, survival is significantly better for those receiving nephrology care before initiating dialysis. Increasing the percentage of patients who are treated by a nephrologist for at least 12 months before starting dialysis is a key part of Healthy People 2020 objectives for chronic kidney disease (CKD).

The new study provides evidence that racial/ethnic disparities in predialysis nephrology care have persisted over the past decade and suggests the need for national strategies targeting differences in access to specialist care for CKD. They conclude: “Potential strategies may include national efforts to enhance collaborations between primary care providers and nephrologists, particularly for members of racial/ethnic minority groups” [Purnell TS, et al. National trends in the association of race and ethnicity with predialysis nephrology care in the United States from 2005 to 2015. JAMA Netw].