• 1.

    Cacari Stone L, et al. State health disparities research in rural America: Gaps and future directions in an era of COVID-19. J Rural Health 2021; 37:460466. doi: 10.1111/jrh.12562

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2.

    Warshaw R. Health disparities affect millions in rural U.S. communities. Association of American Medical Colleges. October 31, 2017. Accessed January 9, 2022. https://www.aamc.org/news-insights/health-disparities-affect-millions-rural-us-communities

    • Search Google Scholar
    • Export Citation
  • 3.

    National Rural Health Association. About rural health care. Accessed January 10, 2022. https://www.ruralhealth.us/about-nrha/about-rural-health-care

    • Search Google Scholar
    • Export Citation
  • 4.

    North Carolina Rural Health Research Program. Rural health snapshot (2017). Cecil Sheps G. Center for Health Services Research, The University of North Carolina at Chapel Hill. May 2017. Accessed January 10, 2022. https://www.shepscenter.unc.edu/wp-content/uploads/dlm_uploads/2017/05/Snapshot2017.pdf

    • Search Google Scholar
    • Export Citation
  • 5.

    Garcia MC, et al. Reducing potentially excess deaths from the five leading causes of death in the rural United States. MMWR Surveill Summ 2017; 66:17. doi: 10.15585/mmwr.ss6602a1

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6.

    Probst JC, et al. Current state of child health in rural America: How context shapes children's health. J Rural Health 2018; 34(Suppl 1):s3s12. doi: 10.1111/jrh.12222

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7.

    Government U.S. Accountability Office. Rural hospital closures: Affected residents had reduced access to health care services. Published December 22, 2020; Publicly released January 21, 2021. Accessed January 10, 2022. https://www.gao.gov/products/gao-21-93

    • Search Google Scholar
    • Export Citation
  • 8.

    Ellison A. Why rural hospital closures hit a record high in 2020. Becker's Healthcare. March 16, 2021. Accessed January 9, 2022. https://www.beckershospitalreview.com/finance/why-rural-hospital-closures-hit-a-record-high-in-2020.html

    • Search Google Scholar
    • Export Citation
  • 9.

    Chartis Center for Rural Health. The rural health safety net under pressure: Rural hospital vulnerability. The Chartis Group. February 2020. Accessed January 9, 2022. https://www.chartis.com/resources/files/CCRH_Vulnerability-Research_FiNAL-02.14.20.pdf

    • Search Google Scholar
    • Export Citation
  • 10.

    Eberth J, et al. ESRD facility characteristics by rurality and risk of closure. South Carolina Rural Health Research Center. November 2017. Accessed January 9, 2022. https://sc.edu/study/colleges_schools/public_health/research/research_centers/sc_rural_health_research_center/documents/161esrdfacilitycharacteristicsbyruralityandriskofclosure.pdf

    • Search Google Scholar
    • Export Citation
  • 11.

    Scholes-Robertson NJ, et al. Patients’ and caregivers’ perspectives on access to kidney replacement therapy in rural communities: Systematic review of qualitative studies. BMJ Open 2020; 10:e037529. doi: 10.1136/bmjopen-2020-037529

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12.

    Jennette CE, et al. Community perspectives on kidney disease and health promotion from at-risk populations in rural North Carolina, USA. Rural Remote Health 2010; 10:1388. https://www.rrh.org.au/journal/article/1388

    • Search Google Scholar
    • Export Citation
  • 13.

    Peters DJ. Community susceptibility and resiliency to COVID-19 across the rural-urban continuum in the United States. J Rural Health 2020; 36:446456. doi: 10.1111/jrh.12477

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14.

    Niu J, et al. Patient health outcomes following dialysis facility closures in the United States. J Am Soc Nephrol 2021; 32:26132621. doi: 10.1681/ASN.2021020244

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15.

    Cohen SA, et al. Rural-urban differences in caregiver burden due to the COVID-19 pandemic among a national sample of informal caregivers. Gerontol Geriatr Med 2021; 7:23337214211025124. doi: 10.1177/23337214211025124

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16.

    Rucker D, et al. Quality of care and mortality are worse in chronic kidney disease patients living in remote areas. Kidney Int 2011; 79:210217. doi: 10.1038/ki.2010.376

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17.

    Tonelli M, et al. Mortality of Canadians treated by peritoneal dialysis in remote locations. Kidney Int 2007; 72:10231028. doi: 10.1038/sj.ki.5002443

  • 18.

    Yan G, et al. The associations between race and geographic area and quality-of-care indicators in patients approaching ESRD. Clin J Am Soc Nephrol 2013; 8:610618. doi: 10.2215/CJN.07780812

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19.

    Patzer RE, et al. Neighborhood poverty and racial disparities in kidney transplant waitlisting. J Am Soc Nephrol 2009; 20:13331340. doi: 10.1681/ASN.2008030335

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20.

    McPherson LJ, et al. Distance to kidney transplant center and access to early steps in the kidney transplantation process in the southeastern United States. Clin J Am Soc Nephrol 2020; 15:539549. doi: 10.2215/CJN.08530719

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21.

    Axelrod DA, et al. The interplay of socioeconomic status, distance to center, and interdonor service area travel on kidney transplant access and outcomes. Clin J Am Soc Nephrol 2010; 5:22762288. doi: 10.2215/CJN.04940610

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22.

    Tonelli M, et al. Access to kidney transplantation among remote- and rural-dwelling patients with kidney failure in the United States. JAMA 2009; 301:16811690. doi: 10.1001/jama.2009.545

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 23.

    James CV, et al. Racial/ethnic health disparities among rural adults–United States, 2012–2015. MMWR Surveill Summ 2017; 66:19. doi: 10.15585/mmwr.ss6623a1

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 24.

    Baweja M. Health care inequities and the rising incidence of kidney diseases. Kidney News Online. American Society of Nephrology. November 1, 2021. Accessed January 9, 2022. https://www.kidneynews.org/view/post/health-care-inequities.xml

    • Search Google Scholar
    • Export Citation

Addressing Kidney Health Disparities among Rural Populations

Kiri BagleyKiri Bagley, MD, MPH, is a Science & Technology Policy Fellow with the American Association for the Advancement of Science and a Clinical Informatics Fellow at the Office of the National Coordinator for Health Information Technology in Washington, DC. Brianna Borsheim, MD, is a Pediatric Resident Physician at Lurie Children's Hospital of Northwestern University Feinberg School of Medicine, Chicago, IL.

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Brianna BorsheimKiri Bagley, MD, MPH, is a Science & Technology Policy Fellow with the American Association for the Advancement of Science and a Clinical Informatics Fellow at the Office of the National Coordinator for Health Information Technology in Washington, DC. Brianna Borsheim, MD, is a Pediatric Resident Physician at Lurie Children's Hospital of Northwestern University Feinberg School of Medicine, Chicago, IL.

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Twenty percent of Americans live in rural areas. Many face health disparities caused by geographic isolation, transportation limitations, and a lack of access to local specialty health care (1, 2). Americans living in rural areas also are more likely to be uninsured, to have lower rates of access to preventive health services, and to engage in unhealthy behaviors (such as tobacco use) (25). They also have greater incidence rates of potentially preventable diseases, including heart disease and stroke, and higher mortality rates than their urban counterparts (2, 4, 5). Likewise, children living in rural America experience higher rates of poverty and obesity and are less likely to obtain preventive health and dental examinations (6). Rural hospital closures pose another obstacle: increasing patients’ travel distances to receive medical services (7). These closures reached a record high in 2020, when the COVID-19 pandemic-related financial strain compounded underlying hardships that rural safety-net institutions already faced (8, 9).

These inequities have significantly impacted kidney health, as evidenced by the greater incidence of kidney failure in rural areas (10). People with chronic kidney disease (CKD) and kidney failure who live in rural areas have difficulty accessing nephrology care. A recently published systematic review by Scholes-Robertson et al. (11) elaborates patient and caregiver perspectives on access to kidney replacement therapy in rural communities. In 18 studies of populations worldwide, rural patients with CKD identified numerous difficulties in accessing care. These included the financial and scheduling burdens incumbent in traveling for care, separation from family and community while receiving care, and other associated sacrifices. Additionally, rural patients frequently reported discomfort with health care systems, stemming from an unfamiliarity with the systems’ language and cultural norms. Although the review by Scholes-Robertson et al. (11) included studies from 8 countries (including the United States), a study of rural North Carolinians’ perspectives about kidney disease reflected similar themes (12). This concordance of findings suggests that kidney disease presents a profound challenge for affected rural populations, domestically and globally.

The COVID-19 pandemic has amplified these rural inequities (13). In addition to rural hospital closures, limited access to home health and broadband presents ongoing barriers for those living in rural America. Rural dialysis centers’ lower patient volumes and profit margins suggest they may be more vulnerable to closure, leaving rural patients to bear a significant travel burden if their home dialysis centers close. Moreover, the disruptions in transportation access for rural dialysis patients during the pandemic further highlight their vulnerability to care discontinuity (10, 14). Caregivers in rural communities, also feeling the impact of the COVID-19 pandemic, are more than twice as likely to report increases in caregiver burden than their urban counterparts (15).

Studies have shown mixed findings when assessing outcomes for patients with CKD and kidney failure in rural areas (1622). This may be, in part, because rural populations, although less heterogeneous than urban populations, are diverse. As such, it is important to recognize that racial and ethnic disparities also occur within rural communities (23). For example, among rural patients with CKD, patients of Black race are less likely to receive early nephrology and dietician care than their White counterparts (18). It is important to identify and address the racial or ethnic disparities within rural communities, in addition to addressing the overall rural-urban disparities between communities.

Rural populations, like many marginalized and underserved groups, are often overlooked. This article highlights the susceptibility, social vulnerability, and substantial health disparities experienced by people with CKD and kidney failure living in rural communities. Currently, there are gaps in the literature investigating rural-urban health disparities. To combat these disparities and inform future policy decisions, additional research assessing the efficacy of different mitigation strategies will be critical. Additionally, improving rural population health is essential to ASN's commitment to health equity and its focus on engaging with social determinants of health to target upstream factors and root causes of disparities (24). As such, rural populations must be a priority in research. Policymakers should continue exploring innovative policy solutions to improve rural health. Clinicians, investigators, and the broader nephrology community should continue to invest in progress toward high-quality care for all.

Disclosure: The views expressed in this article are those of its authors and do not necessarily reflect those of the Office of the National Coordinator for Health IT or the US Department of Health and Human Services.

References

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    Cacari Stone L, et al. State health disparities research in rural America: Gaps and future directions in an era of COVID-19. J Rural Health 2021; 37:460466. doi: 10.1111/jrh.12562

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2.

    Warshaw R. Health disparities affect millions in rural U.S. communities. Association of American Medical Colleges. October 31, 2017. Accessed January 9, 2022. https://www.aamc.org/news-insights/health-disparities-affect-millions-rural-us-communities

    • Search Google Scholar
    • Export Citation
  • 3.

    National Rural Health Association. About rural health care. Accessed January 10, 2022. https://www.ruralhealth.us/about-nrha/about-rural-health-care

    • Search Google Scholar
    • Export Citation
  • 4.

    North Carolina Rural Health Research Program. Rural health snapshot (2017). Cecil Sheps G. Center for Health Services Research, The University of North Carolina at Chapel Hill. May 2017. Accessed January 10, 2022. https://www.shepscenter.unc.edu/wp-content/uploads/dlm_uploads/2017/05/Snapshot2017.pdf

    • Search Google Scholar
    • Export Citation
  • 5.

    Garcia MC, et al. Reducing potentially excess deaths from the five leading causes of death in the rural United States. MMWR Surveill Summ 2017; 66:17. doi: 10.15585/mmwr.ss6602a1

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6.

    Probst JC, et al. Current state of child health in rural America: How context shapes children's health. J Rural Health 2018; 34(Suppl 1):s3s12. doi: 10.1111/jrh.12222

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7.

    Government U.S. Accountability Office. Rural hospital closures: Affected residents had reduced access to health care services. Published December 22, 2020; Publicly released January 21, 2021. Accessed January 10, 2022. https://www.gao.gov/products/gao-21-93

    • Search Google Scholar
    • Export Citation
  • 8.

    Ellison A. Why rural hospital closures hit a record high in 2020. Becker's Healthcare. March 16, 2021. Accessed January 9, 2022. https://www.beckershospitalreview.com/finance/why-rural-hospital-closures-hit-a-record-high-in-2020.html

    • Search Google Scholar
    • Export Citation
  • 9.

    Chartis Center for Rural Health. The rural health safety net under pressure: Rural hospital vulnerability. The Chartis Group. February 2020. Accessed January 9, 2022. https://www.chartis.com/resources/files/CCRH_Vulnerability-Research_FiNAL-02.14.20.pdf

    • Search Google Scholar
    • Export Citation
  • 10.

    Eberth J, et al. ESRD facility characteristics by rurality and risk of closure. South Carolina Rural Health Research Center. November 2017. Accessed January 9, 2022. https://sc.edu/study/colleges_schools/public_health/research/research_centers/sc_rural_health_research_center/documents/161esrdfacilitycharacteristicsbyruralityandriskofclosure.pdf

    • Search Google Scholar
    • Export Citation
  • 11.

    Scholes-Robertson NJ, et al. Patients’ and caregivers’ perspectives on access to kidney replacement therapy in rural communities: Systematic review of qualitative studies. BMJ Open 2020; 10:e037529. doi: 10.1136/bmjopen-2020-037529

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12.

    Jennette CE, et al. Community perspectives on kidney disease and health promotion from at-risk populations in rural North Carolina, USA. Rural Remote Health 2010; 10:1388. https://www.rrh.org.au/journal/article/1388

    • Search Google Scholar
    • Export Citation
  • 13.

    Peters DJ. Community susceptibility and resiliency to COVID-19 across the rural-urban continuum in the United States. J Rural Health 2020; 36:446456. doi: 10.1111/jrh.12477

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14.

    Niu J, et al. Patient health outcomes following dialysis facility closures in the United States. J Am Soc Nephrol 2021; 32:26132621. doi: 10.1681/ASN.2021020244

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15.

    Cohen SA, et al. Rural-urban differences in caregiver burden due to the COVID-19 pandemic among a national sample of informal caregivers. Gerontol Geriatr Med 2021; 7:23337214211025124. doi: 10.1177/23337214211025124

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16.

    Rucker D, et al. Quality of care and mortality are worse in chronic kidney disease patients living in remote areas. Kidney Int 2011; 79:210217. doi: 10.1038/ki.2010.376

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17.

    Tonelli M, et al. Mortality of Canadians treated by peritoneal dialysis in remote locations. Kidney Int 2007; 72:10231028. doi: 10.1038/sj.ki.5002443

  • 18.

    Yan G, et al. The associations between race and geographic area and quality-of-care indicators in patients approaching ESRD. Clin J Am Soc Nephrol 2013; 8:610618. doi: 10.2215/CJN.07780812

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19.

    Patzer RE, et al. Neighborhood poverty and racial disparities in kidney transplant waitlisting. J Am Soc Nephrol 2009; 20:13331340. doi: 10.1681/ASN.2008030335

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20.

    McPherson LJ, et al. Distance to kidney transplant center and access to early steps in the kidney transplantation process in the southeastern United States. Clin J Am Soc Nephrol 2020; 15:539549. doi: 10.2215/CJN.08530719

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21.

    Axelrod DA, et al. The interplay of socioeconomic status, distance to center, and interdonor service area travel on kidney transplant access and outcomes. Clin J Am Soc Nephrol 2010; 5:22762288. doi: 10.2215/CJN.04940610

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22.

    Tonelli M, et al. Access to kidney transplantation among remote- and rural-dwelling patients with kidney failure in the United States. JAMA 2009; 301:16811690. doi: 10.1001/jama.2009.545

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 23.

    James CV, et al. Racial/ethnic health disparities among rural adults–United States, 2012–2015. MMWR Surveill Summ 2017; 66:19. doi: 10.15585/mmwr.ss6623a1

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 24.

    Baweja M. Health care inequities and the rising incidence of kidney diseases. Kidney News Online. American Society of Nephrology. November 1, 2021. Accessed January 9, 2022. https://www.kidneynews.org/view/post/health-care-inequities.xml

    • Search Google Scholar
    • Export Citation
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