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.
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.
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,” appeared 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,” appeared online at http://cjasn.asnjournals.org/ on March 14, 2013.
American Society of Nephrology