1
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He G, Li C, Wang S, Wang H, Ding J. Association of insurance status with chronic kidney disease stage at diagnosis in children. Pediatr Nephrol 2022; 37:2705-2714. [PMID: 35224660 DOI: 10.1007/s00467-022-05493-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/06/2022] [Accepted: 01/27/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Whether medical insurance impacts the timely diagnosis in chronic kidney disease (CKD) children is unknown. We aim to examine the extent to which insurance is associated with access to timely diagnosis and different stages of CKD among a large population of children in China. METHODS A retrospective, cross-sectional study based on China's national hospitalized record database was carried out. Children aged 0-17 years diagnosed as CKD stages 1-5 between June 1, 2013, and December 31, 2018, were included. A diagnosis of advanced CKD stage (CKD stage 4 or 5) was the primary outcome. Multivariable logistic regression model adjusted for age, sex, cross-regional hospitalization, year of diagnosis, and cause of CKD was used to assess the association between insurance status and the stage of CKD when diagnosed. RESULTS A total of 10,256 children (median [interquartile range, IQR] age, 12.4 [7.9, 15.4] years) were included. There were 4716 (46.0%) uninsured children in the included population. The insurance coverage was highest in children 13-17 years old (60.9%). The hospitalized charge was highest in stage 5 uninsured children (median [IQR], ¥13,000.89 [7640.63, 24,585.00]). More uninsured children are diagnosed in CKD stage 4 or 5 (48.1%) than insured children (47.5%). Uninsured children had higher odds (odds ratio [OR] 1.20, [95% CI, 1.08-1.32]) of receiving a diagnosis of CKD stage 4 or 5 compared with insured children. CONCLUSIONS Lack of medical insurance was associated with a more advanced stage of CKD when diagnosed in hospitalized children. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Guohua He
- Department of Pediatrics, Peking University First Hospital, No.1 Xi An Men Da Jie, Beijing, 100034, People's Republic of China
| | - Chenglong Li
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Shengfeng Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Haibo Wang
- Clinical Trial Unit, The First Affiliated Hospital, Sun Yat-Sen University, No.58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China.
| | - Jie Ding
- Department of Pediatrics, Peking University First Hospital, No.1 Xi An Men Da Jie, Beijing, 100034, People's Republic of China.
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2
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Kalyesubula R, Conroy AL, Calice-Silva V, Kumar V, Onu U, Batte A, Kaze FF, Fabian J, Ulasi I. Screening for Kidney Disease in Low- and Middle-Income Countries. Semin Nephrol 2022; 42:151315. [DOI: 10.1016/j.semnephrol.2023.151315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
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3
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Blackmond N, Loh T, Kanke JD, Khilanani U, Weitzman R. Challenges in Management of Kidney Failure in a Free Clinic Setting: A Case Report. Cureus 2022; 14:e26352. [PMID: 35911284 PMCID: PMC9329599 DOI: 10.7759/cureus.26352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2022] [Indexed: 11/07/2022] Open
Abstract
Chronic kidney disease (CKD) is a condition that involves the deterioration of renal function over the course of months to years. Various clinical manifestations occur at the initial insult to the kidney, ranging from subtle changes in metabolic and volume control to asymptomatic hematuria, hypertension, and diabetes. The kidneys can adapt to damage or injury, but if left untreated, then there is a possibility of a gradual decline in renal function that progresses to kidney failure that requires dialysis. The rate of progression between stages of CKD is based upon the underlying disease, presence of comorbidity conditions, treatments, socioeconomic status, genetics, and ethnicity. If an individual’s renal function progresses to kidney failure, then patients may experience a constellation of signs and symptoms that include hyperkalemia, volume overload, hypertension, anemia, and bone disorders. Classification or staging of CKD provides a guide to management and stratification of risk for progression to kidney failure. In this report, we describe a 47-year-old African American male who reported a 25-year history of intermittent homelessness, cocaine, and heroin use but remained free from drug use for 10 years before presenting to our clinic. The patient was diagnosed with hypertension and stage 3 kidney disease in his 30s but was unable to have regular follow-up appointments with a physician due to a lack of access to care. The patient presented asymptomatic with an estimated glomerular filtration rate of 14 mL/min and creatinine of 5.42 mg/dL. We stabilized his hypertension and consulted nephrology to assess the need and timing for dialysis. Once approved for Medicare, the patient was able to be seen within 72 hours and started on dialysis shortly after. He is currently awaiting a kidney transplant. In this case, we describe and highlight the gaps in care for the medically uninsured, specifically patients with CKD. Our patient was diagnosed with stage 3 kidney disease 17 years before presenting to the Gary Burnstein Clinic. The gaps in accessible healthcare prevented him from accessing treatments he desperately needed. We also highlight the achievements and barriers free health clinics face on a day-to-day basis when trying to manage complex medical needs. We were able to provide high-quality healthcare to bridge the gap in access to care and ultimately get the patient the proper treatment.
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4
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Lyas C. It’s Not All Even. PHYSICIAN ASSISTANT CLINICS 2022. [DOI: 10.1016/j.cpha.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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5
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Novick TK, Diaz S, Barrios F, Cubas D, Choudhary K, Nader P, ElKhoury R, Cervantes L, Jacobs EA. Perspectives on Kidney Disease Education and Recommendations for Improvement Among Latinx Patients Receiving Emergency-Only Hemodialysis. JAMA Netw Open 2021; 4:e2124658. [PMID: 34499133 PMCID: PMC8430451 DOI: 10.1001/jamanetworkopen.2021.24658] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE In most states, undocumented Latinx immigrants with kidney failure receive dialysis in acute care settings on an emergency-only basis. How much kidney disease education Latinx immigrants receive and how to improve kidney disease education and outreach among Latinx populations are unknown. OBJECTIVE To understand the kidney disease educational gaps of Latinx individuals who need but lack access to scheduled outpatient dialysis. DESIGN, SETTING, AND PARTICIPANTS This qualitative study used semistructured interviews in a Texas hospital system from March 2020 to January 2021 with 15 individuals who received emergency-only dialysis when they were first diagnosed with kidney failure. Demographic information was collected, and a thematic analysis was performed using the constant comparative method on interviews after they were audio-recorded, translated, and transcribed verbatim. Data analysis was performed from April 2020 to February 2021. MAIN OUTCOMES AND MEASURES Subthemes and themes from semistructured interviews. RESULTS All 15 persons interviewed (9 male individuals [60%]; mean [SD] age, 51 [17] years) identified as Hispanic, 11 (73%) were born in Mexico, and none reported knowing about their kidney disease more than 6 months before starting dialysis. The themes identified were (1) lack of kidney disease awareness, (2) education provided was incomplete and poor quality, (3) lack of culturally concordant communication and care, (4) elements that Latinx patients receiving emergency-only dialysis want in their education, (5) facilitators of patient activation and coping, and (6) Latinx patient recommendations to improve community outreach. CONCLUSIONS AND RELEVANCE Latinx adults receiving emergency-only dialysis are usually unaware of their kidney disease until shortly before or after they start dialysis, and the education they receive is poor quality and often not culturally tailored. Participants made feasible recommendations on how to improve education and outreach among Latinx communities.
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Affiliation(s)
- Tessa K. Novick
- Division of Nephrology, University of Texas at Austin, Dell Medical School, Austin
- Department of Internal Medicine, University of Texas at Austin, Dell Medical School, Austin
| | - Santiago Diaz
- Department of Internal Medicine, University of Texas at Austin, Dell Medical School, Austin
| | - Francisco Barrios
- Department of Internal Medicine, University of Texas at Austin, Dell Medical School, Austin
| | - Doris Cubas
- Department of Internal Medicine, University of Texas at Austin, Dell Medical School, Austin
| | | | - Paul Nader
- Division of Nephrology, University of Texas at Austin, Dell Medical School, Austin
- Department of Internal Medicine, University of Texas at Austin, Dell Medical School, Austin
| | - Raymonda ElKhoury
- Division of Nephrology, University of Texas at Austin, Dell Medical School, Austin
- Department of Internal Medicine, University of Texas at Austin, Dell Medical School, Austin
| | - Lilia Cervantes
- Division of General Internal Medicine and Hospital Medicine, University of Colorado, Boulder
| | - Elizabeth A. Jacobs
- Department of Internal Medicine, University of Texas at Austin, Dell Medical School, Austin
- Maine Medical Center Research Institute, Scarborough
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6
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Pereira RI, Cervantes L. Reducing the Burden of CKD among Latinx: A Community-Based Approach. Clin J Am Soc Nephrol 2021; 16:812-814. [PMID: 33441466 PMCID: PMC8259478 DOI: 10.2215/cjn.12890820] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Rocio I. Pereira
- Department of Medicine, Denver Health, Denver, Colorado,Department of Medicine, University of Colorado, Aurora, Colorado
| | - Lilia Cervantes
- Department of Medicine, Denver Health, Denver, Colorado,Department of Medicine, University of Colorado, Aurora, Colorado,Office of Research, Denver Health, Denver, Colorado
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7
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Luyckx VA, Cherney DZ, Bello AK. Preventing CKD in Developed Countries. Kidney Int Rep 2020; 5:263-277. [PMID: 32154448 PMCID: PMC7056854 DOI: 10.1016/j.ekir.2019.12.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 12/09/2019] [Indexed: 12/14/2022] Open
Abstract
Chronic kidney disease (CKD) is an important public health concern in developed countries because of both the number of people affected and the high cost of care when prevention strategies are not effectively implemented. Prevention should start at the governance level with the institution of multisectoral polices supporting sustainable development goals and ensuring safe and healthy environments. Primordial prevention of CKD can be achieved through implementation of measures to ensure healthy fetal (kidney) development. Public health strategies to prevent diabetes, hypertension, and obesity as risk factors for CKD are important. These approaches are cost-effective and reduce the overall noncommunicable disease burden. Strategies to prevent nontraditional CKD risk factors, including nephrotoxin exposure, kidney stones, infections, environmental exposures, and acute kidney injury (AKI), need to be tailored to local needs and epidemiology. Early diagnosis and treatment of CKD risk factors such as diabetes, obesity, and hypertension are key for primary prevention of CKD. CKD tends to occur more frequently and to progress more rapidly among indigenous, minority, and socioeconomically disadvantaged populations. Special attention is required to meet the CKD prevention needs of these populations. Effective secondary prevention of CKD relies on screening of individuals at risk to detect and treat CKD early, using established and emerging strategies. Within high-income countries, barriers to accessing effective CKD therapies must be recognized, and public health strategies must be developed to overcome these obstacles, including training and support at the primary care level to identify individuals at risk of CKD, and appropriately implement clinical practice guidelines.
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Affiliation(s)
- Valerie A. Luyckx
- Institute of Biomedical Ethics and the History of Medicine, University of Zurich, Zurich, Switzerland
- Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
- Nephrology, Cantonal Hospital Graubunden, Chur, Switzerland
| | - David Z.I. Cherney
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Aminu K. Bello
- Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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8
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Purnell TS, Luo X, Crews DC, Bae S, Ruck JM, Cooper LA, Grams ME, Henderson ML, Waldram MM, Johnson M, Segev DL. Neighborhood Poverty and Sex Differences in Live Donor Kidney Transplant Outcomes in the United States. Transplantation 2019; 103:2183-2189. [PMID: 30768570 DOI: 10.1097/tp.0000000000002654] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neighborhood poverty has been associated with worse outcomes after live donor kidney transplantation (LDKT), and prior work suggests that women with kidney disease may be more susceptible to the negative influence of poverty than men. As such, our goal was to examine whether poverty differentially affects women in influencing LDKT outcomes. METHODS Using data from the Scientific Registry of Transplant Recipients and US Census, we performed multivariable Cox regression to compare outcomes among 18 955 women and 30 887 men who received a first LDKT in 2005-2014 with follow-up through December 31, 2016. RESULTS Women living in poor (adjusted hazard ratio [aHR], 1.30; 95% confidence interval [CI], 1.13-1.50) and middle-income (aHR, 1.26; 95% CI, 1.14-1.40) neighborhoods had higher risk of graft loss than men, but there were no differences in wealthy areas (aHR, 1.07; 95% CI, 0.88-1.29). Women living in wealthy (aHR, 0.71; 95% CI, 0.59-0.87) and middle-income (aHR, 0.82; 95% CI, 0.74-0.92) neighborhoods incurred a survival advantage over men, but there were no statistically significant differences in mortality in poor areas (aHR, 0.85; 95% CI, 0.72-1.01). CONCLUSIONS Given our findings that poverty is more strongly associated with graft loss in women, targeted efforts are needed to specifically address mechanisms driving these disparities in LDKT outcomes.
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Affiliation(s)
- Tanjala S Purnell
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, MD
| | - Xun Luo
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Deidra C Crews
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, MD
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Sunjae Bae
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jessica M Ruck
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Lisa A Cooper
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, MD
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Macey L Henderson
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, MD
| | - Madeleine M Waldram
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, MD
| | - Morgan Johnson
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, MD
| | - Dorry L Segev
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, MD
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9
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The Affordable Care Act and Trends in Insurance Coverage and Disease Awareness Among Non-elderly Individuals with Kidney Disease. J Gen Intern Med 2019; 34:351-353. [PMID: 30367328 PMCID: PMC6420559 DOI: 10.1007/s11606-018-4713-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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10
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Hall YN. Social Determinants of Health: Addressing Unmet Needs in Nephrology. Am J Kidney Dis 2018; 72:582-591. [DOI: 10.1053/j.ajkd.2017.12.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 12/18/2017] [Indexed: 11/11/2022]
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11
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Abstract
PURPOSE OF REVIEW The purposes of this review are to identify population characteristics of important risk factors for the development and progression of diabetic kidney disease (DKD) in the United States and to discuss barriers and opportunities to improve awareness, management, and outcomes in patients with DKD. RECENT FINDINGS The major risk factors for the development and progression of DKD include hyperglycemia, hypertension, and albuminuria. DKD disproportionately affects minorities and individuals with low educational and socioeconomic status. Barriers to effective management of DKD include the following: (a) limited patient and healthcare provider awareness of DKD, (b) lack of timely referrals of patients to a nephrologist, (c) low patient healthcare literacy, and (d) insufficient access to healthcare and health insurance. Increased patient and physician awareness of DKD has been shown to enhance patient outcomes. Multifactorial and multidisciplinary interventions targeting multiple risk factors and patient/physician education may provide better outcomes in patients with DKD.
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Affiliation(s)
- O Kenrik Duru
- Department of Medicine, Division of General Internal Medicine/Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, 10940 Wilshire Blvd, Suite 700, Los Angeles, CA, 90024, USA.
| | | | | | - Keith Norris
- Department of Medicine, Division of General Internal Medicine/Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, 10940 Wilshire Blvd, Suite 700, Los Angeles, CA, 90024, USA
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12
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Gatwood J, Chisholm-Burns M, Davis R, Thomas F, Potukuchi P, Hung A, Kovesdy CP. Evidence of chronic kidney disease in veterans with incident diabetes mellitus. PLoS One 2018; 13:e0192712. [PMID: 29425235 PMCID: PMC5806889 DOI: 10.1371/journal.pone.0192712] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 01/29/2018] [Indexed: 01/13/2023] Open
Abstract
While chronic kidney disease (CKD) is regularly evaluated among patients with diabetes, kidney function may be significantly impaired before diabetes is diagnosed. Moreover, disparities in the severity of CKD in such a population are likely. This study evaluated the extent of CKD in a national cohort of 36,764 US veterans first diagnosed with diabetes between 2003 and 2013 and prior to initiating oral antidiabetic therapy. Evidence of CKD (any stage) at the time of diabetes diagnosis was determined using eGFR and urine-albumin-creatinine ratios, the odds of which were assessed using logistic regression controlling for patient characteristics. CKD was evident in 31.6% of veterans prior to being diagnosed with diabetes (age and gender standardized rates: 241.8 per 1,000 adults [overall] and 247.7 per 1,000 adult males), over half of whom had at least moderate kidney disease (stage 3 or higher). The odds of CKD tended to increase with age (OR: 1.88; 95% CI: 1.82-1.93), hemoglobin A1C (OR: 1.05; 95% CI: 1.04-1.06), systolic blood pressure (OR: 1.04; 95% CI: 1.027-1.043), and BMI (OR: 1.016; 95% CI: 1.011-1.020). Both Asian Americans (OR: 1.53; 95% CI: 1.15-2.04) and African Americans (OR: 1.11; 95% CI: 1.03-1.20) had higher adjusted odds of CKD compared to whites, and prevalence was highest in the Upper Midwest and parts of the Mid-South. Results suggest that evidence of CKD is common among veterans before a diabetes diagnosis, and certain populations throughout the country, such as minorities, may be afflicted at higher rates.
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Affiliation(s)
- Justin Gatwood
- University of Tennessee Health Science Center, College of Pharmacy, Memphis, TN, United States of America
| | - Marie Chisholm-Burns
- University of Tennessee Health Science Center, College of Pharmacy, Memphis, TN, United States of America
| | - Robert Davis
- University of Tennessee Health Science Center, Center for Biomedical Informatics, Memphis, TN, United States of America
| | - Fridtjof Thomas
- University of Tennessee Health Science Center, Department of Preventive Medicine, Memphis, TN, United States of America
| | - Praveen Potukuchi
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, United States of America
| | - Adriana Hung
- Vanderbilt University School of Medicine, Nashville, TN, United States of America
- VA Tennessee Valley Healthcare System, Nashville, TN, United States of America
| | - Csaba P. Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, United States of America
- Memphis VA Medical Center, Memphis, TN, United States of America
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13
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Wang V, Vilme H, Maciejewski ML, Boulware LE. The Economic Burden of Chronic Kidney Disease and End-Stage Renal Disease. Semin Nephrol 2018; 36:319-30. [PMID: 27475662 DOI: 10.1016/j.semnephrol.2016.05.008] [Citation(s) in RCA: 185] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The growing prevalence and progression of chronic kidney disease (CKD) raises concerns about our capacity to manage its economic burden to patients, caregivers, and society. The societal direct and indirect costs of CKD and end-stage renal disease are substantial and increase throughout disease progression. There is significant variability in the evidence about direct and indirect costs attributable to CKD and end-stage renal disease, with the most complete evidence concentrated on direct health care costs of patients with advanced to end-stage CKD. There are substantial gaps in evidence that need to be filled to inform clinical practice and policy.
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Affiliation(s)
- Virginia Wang
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC; Health Services Research and Development, Durham VA Medical Center, Durham, NC.
| | - Helene Vilme
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Matthew L Maciejewski
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC; Health Services Research and Development, Durham VA Medical Center, Durham, NC
| | - L Ebony Boulware
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
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14
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Harding K, Mersha TB, Vassalotti JA, Webb FJ, Nicholas SB. Current State and Future Trends to Optimize the Care of Chronic Kidney Disease in African Americans. Am J Nephrol 2017; 46:176-186. [PMID: 28787720 PMCID: PMC5892790 DOI: 10.1159/000479481] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND African Americans (AAs) suffer the widest gaps in chronic kidney disease (CKD) outcomes compared to Caucasian Americans (CAs) and this is because of the disparities that exist in both health and healthcare. In fact, the prevalence of CKD is 3.5 times higher in AAs compared to CAs. The disparities exist at all stages of CKD. Importantly, AAs are 10 times more likely to develop hypertension-related kidney failure and 3 times more likely to progress to kidney failure compared to CAs. SUMMARY Several factors contribute to these disparities including genetic and social determinants, late referrals, poor care coordination, medication adherence, and low recruitment in clinical trials. Key Messages: The development and implementation of CKD-related evidence-based approaches, such as clinical and social determinant assessment tools for medical interventions, more widespread outreach programs, strategies to improve medication adherence, safe and effective pharmacological treatments to control or eliminate CKD, as well as the use of health information technology, and patient-engagement programs for improved CKD outcomes may help to positively impact these disparities among AAs.
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Affiliation(s)
| | - Tesfaye B. Mersha
- Department of Pediatrics, Cincinnati Children’s Hospital
Medical Center, University of Cincinnati, Cincinnati, OH
| | - Joseph A. Vassalotti
- National Kidney Foundation, Icahn School of Medicine at Mount Sinai,
New York, NY
- Division of Nephrology, Department of Medicine, Icahn School of
Medicine at Mount Sinai, New York, NY
| | - Fern J. Webb
- Department of Community Health and Family Medicine University of
Florida College of Medicine, Jacksonville, FL
| | - Susanne B. Nicholas
- Divisions of Nephrology and Endocrinology, Department of Medicine,
David Geffen School of Medicine at University of California, Los Angeles, CA,
USA
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15
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Webster AC, Nagler EV, Morton RL, Masson P. Chronic Kidney Disease. Lancet 2017; 389:1238-1252. [PMID: 27887750 DOI: 10.1016/s0140-6736(16)32064-5] [Citation(s) in RCA: 2026] [Impact Index Per Article: 289.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/29/2016] [Accepted: 07/19/2016] [Indexed: 02/08/2023]
Abstract
The definition and classification of chronic kidney disease (CKD) have evolved over time, but current international guidelines define this condition as decreased kidney function shown by glomerular filtration rate (GFR) of less than 60 mL/min per 1·73 m2, or markers of kidney damage, or both, of at least 3 months duration, regardless of the underlying cause. Diabetes and hypertension are the main causes of CKD in all high-income and middle-income countries, and also in many low-income countries. Incidence, prevalence, and progression of CKD also vary within countries by ethnicity and social determinants of health, possibly through epigenetic influence. Many people are asymptomatic or have non-specific symptoms such as lethargy, itch, or loss of appetite. Diagnosis is commonly made after chance findings from screening tests (urinary dipstick or blood tests), or when symptoms become severe. The best available indicator of overall kidney function is GFR, which is measured either via exogenous markers (eg, DTPA, iohexol), or estimated using equations. Presence of proteinuria is associated with increased risk of progression of CKD and death. Kidney biopsy samples can show definitive evidence of CKD, through common changes such as glomerular sclerosis, tubular atrophy, and interstitial fibrosis. Complications include anaemia due to reduced production of erythropoietin by the kidney; reduced red blood cell survival and iron deficiency; and mineral bone disease caused by disturbed vitamin D, calcium, and phosphate metabolism. People with CKD are five to ten times more likely to die prematurely than they are to progress to end stage kidney disease. This increased risk of death rises exponentially as kidney function worsens and is largely attributable to death from cardiovascular disease, although cancer incidence and mortality are also increased. Health-related quality of life is substantially lower for people with CKD than for the general population, and falls as GFR declines. Interventions targeting specific symptoms, or aimed at supporting educational or lifestyle considerations, make a positive difference to people living with CKD. Inequity in access to services for this disease disproportionally affects disadvantaged populations, and health service provision to incentivise early intervention over provision of care only for advanced CKD is still evolving in many countries.
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Affiliation(s)
- Angela C Webster
- Sydney School of Public Health, University of Sydney, NSW, Australia; Centre for Transplant and Renal research, Westmead Hospital, Westmead, NSW, Australia.
| | - Evi V Nagler
- Renal Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
| | - Philip Masson
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
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16
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Robles-Osorio ML, Sabath E. Social disparities, risk factors and chronic kidney disease. Nefrologia 2016; 36:577-579. [PMID: 27436833 DOI: 10.1016/j.nefro.2016.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 02/15/2016] [Accepted: 05/07/2016] [Indexed: 11/28/2022] Open
Affiliation(s)
| | - Ernesto Sabath
- Facultad de Ciencias Naturales, Universidad Autónoma de Querétaro, Querétaro, México; Departamento de Nefrología, Servicios de Salud del Estado de Querétaro, Querétaro, México.
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17
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Xie Y, Maziarz M, Tuot DS, Chertow GM, Himmelfarb J, Hall YN. Risk prediction to inform surveillance of chronic kidney disease in the US Healthcare Safety Net: a cohort study. BMC Nephrol 2016; 17:57. [PMID: 27276913 PMCID: PMC4898308 DOI: 10.1186/s12882-016-0272-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 06/01/2016] [Indexed: 01/13/2023] Open
Abstract
Background The capacity of electronic health record (EHR) data to guide targeted surveillance in chronic kidney disease (CKD) is unclear. We sought to leverage EHR data for predicting risk of progressing from CKD to end-stage renal disease (ESRD) to help inform surveillance of CKD among vulnerable patients from the healthcare safety-net. Methods We conducted a retrospective cohort study of adults (n = 28,779) with CKD who received care within 2 regional safety-net health systems during 1996–2009 in the Western United States. The primary outcomes were progression to ESRD and death as ascertained by linkage with United States Renal Data System and Social Security Administration Death Master files, respectively, through September 29, 2011. We evaluated the performance of 3 models which included demographic, comorbidity and laboratory data to predict progression of CKD to ESRD in conditions commonly targeted for disease management (hypertension, diabetes, chronic viral diseases and severe CKD) using traditional discriminatory criteria (AUC) and recent criteria intended to guide population health management strategies. Results Overall, 1730 persons progressed to end-stage renal disease and 7628 died during median follow-up of 6.6 years. Performance of risk models incorporating common EHR variables was highest in hypertension, intermediate in diabetes and chronic viral diseases, and lowest in severe CKD. Surveillance of persons who were in the highest quintile of ESRD risk yielded 83–94 %, 74–95 %, and 75–82 % of cases who progressed to ESRD among patients with hypertension, diabetes and chronic viral diseases, respectively. Similar surveillance yielded 42–71 % of ESRD cases among those with severe CKD. Discrimination in all conditions was universally high (AUC ≥0.80) when evaluated using traditional criteria. Conclusions Recently proposed discriminatory criteria account for varying risk distribution and when applied to common clinical conditions may help to inform surveillance of CKD in diverse populations. Electronic supplementary material The online version of this article (doi:10.1186/s12882-016-0272-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yuxiang Xie
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Marlena Maziarz
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Delphine S Tuot
- Division of Nephrology, University of California San Francisco and San Francisco General Hospital, San Francisco, CA, USA
| | - Glenn M Chertow
- Division of Nephrology, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Jonathan Himmelfarb
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Yoshio N Hall
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA, USA. .,Kidney Research Institute, University of Washington, 325 9th Ave, Box 359606, Seattle, WA, 98104, USA.
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18
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Saunders MR, Ricardo AC, Chen J, Chin MH, Lash JP. Association between insurance status and mortality in individuals with albuminuria: an observational cohort study. BMC Nephrol 2016; 17:27. [PMID: 26960447 PMCID: PMC4784311 DOI: 10.1186/s12882-016-0239-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 03/01/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the general population, the association between uninsurance and mortality is well established. We sought to evaluate the association of health insurance status with mortality among working-age participants with albuminuria in the Third National Health and Nutrition Examination Survey, 1988-1994 (NHANES III). METHODS We used data from non-elderly adult participants (18-64) of NHANES III (1988-1994), a nationally representative study of the US civilian, noninstitutionalized population, who provided information on insurance and who had albuminuria, defined as a urine albumin-to-creatinine ratio [UACR] ≥ 30 mg/g and their subsequent mortality to December 31, 2006. Cox proportional hazards models were used to determine associations between insurance status and all-cause mortality and cardiovascular mortality in patients with CKD while adjusting in a stepwise fashion for sociodemographic factors, co-morbidities, and co-morbidity severity/control covariates. RESULTS In our sample of individuals with albuminuria (n = 903), mean estimated glomerular filtration rate (eGFR) was 101.6 ml/min/1.73 m(2) with 4.7 % with an eGFR <60. Approximately 15 % of the sample was uninsured, 18 % had public insurance and 67 % had private insurance. Compared to individuals with private insurance, those with public insurance or no insurance were significantly more likely to be a racial or ethnic minority, to have income <200 % below the federal poverty level, to have less than high school education; and they were less likely to be married and to report good or excellent health, all p < 0.05. Being uninsured or having public insurance was associated with increased all-cause mortality in the fully adjusted model (HR 2.97 and 3.65, respectively, p < 0.05). There was no significant relationship between insurance status and cardiovascular mortality. CONCLUSIONS In a nationally representative sample of individuals with albuminuria, uninsurance and public insurance were associated with increased mortality compared to the private insurance even after controlling for sociodemographic, health status, and health care variables. Improving access to care and the quality of care received may potentially reduce mortality in individuals with evidence of early CKD.
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Affiliation(s)
- Milda R Saunders
- University of Chicago Medicine, 5841 S. Maryland, MC 5000, Chicago, IL, 60637, USA.
| | | | - Jinsong Chen
- University of Illinois at Chicago, 820 Wood St, MC 793, Chicago, IL, 60612, USA.
| | - Marshall H Chin
- University of Chicago Medicine, 5841 S. Maryland, MC 2007, Chicago, IL, 60637, USA.
| | - James P Lash
- University of Illinois at Chicago, 820 Wood St, MC 793, Chicago, IL, 60612, USA.
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19
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Tuot DS, Velasquez A, McCulloch CE, Banerjee T, Zhu Y, Hsu CY, Handley M, Schillinger D, Powe NR. The Kidney Awareness Registry and Education (KARE) study: protocol of a randomized controlled trial to enhance provider and patient engagement with chronic kidney disease. BMC Nephrol 2015; 16:166. [PMID: 26494562 PMCID: PMC4618520 DOI: 10.1186/s12882-015-0168-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/14/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is common and is associated with excess mortality and morbidity. Better management could slow progression of disease, prevent metabolic complications, and reduce cardiovascular outcomes. Low patient awareness of CKD and ineffective patient-provider communication can impede such efforts. We developed provider and patient-directed interventions that harness health information technology to enhance provider recognition of CKD and delivery of guideline concordant care and augment patient understanding and engagement in CKD care. METHODS/DESIGN We report the design and protocol of the Kidney Awareness Registry and Education (KARE) Study, a 2x2 factorial randomized controlled trial that examines the impact of a multi-level intervention on health outcomes among low-income English, Spanish and Cantonese-speaking patients with CKD in a safety net system. The intervention includes: (1) implementation of a primary care electronic CKD registry that notifies practice teams of patients' CKD status and employs a patient profile and quarterly feedback to encourage provision of guideline-concordant care at point-of-care and via outreach; and (2) a language-concordant, culturally-sensitive self-management support program that consists of automated telephone modules, provision of low-literacy written patient-educational materials and telephone health coaching. The primary outcomes of the trial are changes in systolic blood pressure (BP) and the proportion of patients with BP control (≤ 140/90 mmHg) after one year. Secondary outcomes include patient understanding of CKD, participation in healthy behaviors, and practice team delivery of guideline-concordant CKD care. DISCUSSION Results from the KARE study will provide data on the feasibility, effectiveness, and acceptability of technology-based interventions that support primary care efforts at improving health outcomes among vulnerable patients with CKD. TRIAL REGISTRATION ClinicalTrials.gov, number: NCT01530958.
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Affiliation(s)
- Delphine S Tuot
- Division of Nephrology, University of California, San Francisco, San Francisco, CA, 94143, USA.
- Center for Vulnerable Populations at San Francisco General Hospital, San Francisco, CA, USA.
- Renal Center at San Francisco General Hospital, 1001 Potrero Avenue Bldg 100, Room 342, San Francisco, CA, 94110, USA.
| | - Alexandra Velasquez
- Division of Nephrology, University of California, San Francisco, San Francisco, CA, 94143, USA.
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, 94143, USA.
| | - Tanushree Banerjee
- Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94143, USA.
- Center for Vulnerable Populations at San Francisco General Hospital, San Francisco, CA, USA.
| | - Yunnuo Zhu
- Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94143, USA.
| | - Chi-yuan Hsu
- Division of Nephrology, University of California, San Francisco, San Francisco, CA, 94143, USA.
| | - Margaret Handley
- Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94143, USA.
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, 94143, USA.
| | - Dean Schillinger
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, 94143, USA.
- Center for Vulnerable Populations at San Francisco General Hospital, San Francisco, CA, USA.
| | - Neil R Powe
- Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94143, USA.
- Center for Vulnerable Populations at San Francisco General Hospital, San Francisco, CA, USA.
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20
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Morton RL, Schlackow I, Mihaylova B, Staplin ND, Gray A, Cass A. The impact of social disadvantage in moderate-to-severe chronic kidney disease: an equity-focused systematic review*. Nephrol Dial Transplant 2015; 31:46-56. [DOI: 10.1093/ndt/gfu394] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 11/28/2014] [Indexed: 11/12/2022] Open
Abstract
Abstract
It is unclear whether a social gradient in health outcomes exists for people with moderate-to-severe chronic kidney disease (CKD). We critically review the literature for evidence of social gradients in health and investigate the ‘suitability’ of statistical analyses in the primary studies. In this equity-focused systematic review among adults with moderate-to-severe CKD, factors of disadvantage included gender, race/ethnicity, religion, education, socio-economic status or social capital, occupation and place of residence. Outcomes included access to healthcare, kidney disease progression, cardiovascular events, all-cause mortality and suitability of analyses. Twenty-four studies in the pre-dialysis population and 34 in the dialysis population representing 8.9 million people from 10 countries were included. In methodologically suitable studies among pre-dialysis patients, a significant social gradient was observed in access to healthcare for those with no health insurance and no home ownership. Low income and no home ownership were associated with higher cardiovascular event rates and higher mortality [HR 1.94, 95% confidence interval (CI) 1.27–2.98; HR 1.28, 95% CI 1.04–1.58], respectively. In methodologically suitable studies among dialysis patients, females, ethnic minorities, those with low education, no health insurance, low occupational level or no home ownership were significantly less likely to access cardiovascular healthcare than their more advantaged dialysis counterparts. Low education level and geographic remoteness were associated with higher cardiovascular event rates and higher mortality (HR 1.54, 95% CI 1.01–2.35; HR 1.21, 95% CI 1.08–1.37), respectively. Socially disadvantaged pre-dialysis and dialysis patients experience poorer access to specialist cardiovascular health services, and higher rates of cardiovascular events and mortality than their more advantaged counterparts.
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Affiliation(s)
- Rachael Lisa Morton
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Iryna Schlackow
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Borislava Mihaylova
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Natalie Dawn Staplin
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
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21
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Nicholas SB, Kalantar-Zadeh K, Norris KC. Socioeconomic disparities in chronic kidney disease. Adv Chronic Kidney Dis 2015; 22:6-15. [PMID: 25573507 DOI: 10.1053/j.ackd.2014.07.002] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 07/11/2014] [Accepted: 07/16/2014] [Indexed: 01/13/2023]
Abstract
CKD is a national public health problem that afflicts persons of all segments of society. Although racial/ethnic disparities in advanced CKD including dialysis-dependent populations have been well established, the finding of differences in CKD incidence, prevalence, and progression across different socioeconomic groups and racial and ethnic strata has only recently started to receive significant attention. Socioeconomics may exert both interdependent and independent effects on CKD and its complications and may confound racial and ethnic disparities. Socioeconomic constellations influence not only access to quality care for CKD risk factors and CKD treatment but may mediate many of the cultural and environmental determinants of health that are becoming more widely recognized as affecting complex medical disorders. In this article, we have reviewed the available literature pertaining to the role of socioeconomic status and economic factors in both non-dialysis-dependent CKD and ESRD. Advancing our understanding of the role of socioeconomic factors in patients with or at risk for CKD can lead to improved strategies for disease prevention and management.
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22
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Tuot DS, Grubbs V. Chronic kidney disease care in the US safety net. Adv Chronic Kidney Dis 2015; 22:66-73. [PMID: 25573515 DOI: 10.1053/j.ackd.2014.05.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 05/20/2014] [Accepted: 05/22/2014] [Indexed: 11/11/2022]
Abstract
The US Health Care System provides a patchwork of services, known as the safety net, for the uninsured, underinsured, and indigent populations who would otherwise have little access to health care services. Individuals who rely on safety-net facilities are from racial/ethnic minority groups, have low socioeconomic status, and often have low health literacy and/or limited English proficiency. They shoulder a disproportionate burden of CKD in the United States and experience excess CKD-associated morbidity and mortality. Suboptimal delivery of CKD care may be contributing and is an area of active translational research. Several initiatives that show promise in improving safety-net CKD care delivery include those that enhance diagnostic and management skills of primary care providers, rely on comprehensive care management programs led by nonphysicians, and leverage technology to enhance patient access to virtual nephrology expertise. Uncovering better ways to translate scientific evidence into practice for vulnerable patients with CKD is a formidable challenge that will require national surveillance of CKD quality measures across diverse ambulatory health systems, including safety nets. Only then will the nephrology community be to identify and share best practices to enhance health and mitigate disparities of care among patients with CKD.
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23
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Maziarz M, Black RA, Fong CT, Himmelfarb J, Chertow GM, Hall YN. Evaluating risk of ESRD in the urban poor. J Am Soc Nephrol 2014; 26:1434-42. [PMID: 25475746 DOI: 10.1681/asn.2014060546] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 08/22/2014] [Indexed: 01/13/2023] Open
Abstract
The capacity of risk prediction to guide management of CKD in underserved health settings is unknown. We conducted a retrospective cohort study of 28,779 adults with nondialysis-requiring CKD who received health care in two large safety net health systems during 1996-2009 and were followed for ESRD through September of 2011. We developed and evaluated the performance of ESRD risk prediction models using recently proposed criteria designed to inform population health approaches to disease management: proportion of cases followed and proportion that needs to be followed. Overall, 1730 persons progressed to ESRD during follow-up (median follow-up=6.6 years). ESRD risk for time frames up to 5 years was highly concentrated among relatively few individuals. A predictive model using five common variables (age, sex, race, eGFR, and dipstick proteinuria) performed similarly to more complex models incorporating extensive sociodemographic and clinical data. Using this model, 80% of individuals who eventually developed ESRD were among the 5% of cohort members at the highest estimated risk for ESRD at 1 year. Similarly, a program that followed 8% and 13% of individuals at the highest ESRD risk would have included 80% of those who eventually progressed to ESRD at 3 and 5 years, respectively. In this underserved health setting, a simple five-variable model accurately predicts most cases of ESRD that develop within 5 years. Applying risk prediction using a population health approach may improve CKD surveillance and management of vulnerable groups by directing resources to a small subpopulation at highest risk for progressing to ESRD.
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Affiliation(s)
- Marlena Maziarz
- Kidney Research Institute, Department of Medicine, Department of Biostatistics, and
| | - R Anthony Black
- Biomedical Informatics Consult Team, Institute of Translational Health Sciences, University of Washington, Seattle, Washington; and
| | - Christine T Fong
- Biomedical Informatics Consult Team, Institute of Translational Health Sciences, University of Washington, Seattle, Washington; and
| | | | - Glenn M Chertow
- School of Medicine, Stanford University, Palo Alto, California
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24
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Boyarsky BJ, Massie AB, Alejo J, Van Arendonk KJ, Wildonger S, Garonzik-Wang JM, Montgomery RA, Deshpande NA, Muzaale AD, Segev DL. Experiences obtaining insurance after live kidney donation. Am J Transplant 2014; 14:2168-72. [PMID: 25041695 PMCID: PMC4194161 DOI: 10.1111/ajt.12819] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 04/29/2014] [Accepted: 05/04/2014] [Indexed: 01/25/2023]
Abstract
The impact of kidney donation on the ability to change or initiate health or life insurance following donation is unknown. To quantify this risk, we surveyed 1046 individuals who donated a kidney at our center between 1970 and 2011. Participants were asked whether they changed or initiated health or life insurance after donation, and if they had any difficulty doing so. Among 395 donors who changed or initiated health insurance after donation, 27 (7%) reported difficulty; among those who reported difficulty, 15 were denied altogether, 12 were charged a higher premium and 8 were told they had a preexisting condition because they were kidney donors. Among 186 donors who changed or initiated life insurance after donation, 46 (25%) reported difficulty; among those who reported difficulty, 23 were denied altogether, 27 were charged a higher premium and 17 were told they had a preexisting condition because they were kidney donors. In this single-center study, a high proportion of kidney donors reported difficulty changing or initiating insurance, particularly life insurance. These practices by insurers create unnecessary burden and stress for those choosing to donate and could negatively impact the likelihood of live kidney donation among those considering donation.
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Affiliation(s)
- Brian J. Boyarsky
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Jennifer Alejo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kyle J. Van Arendonk
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Spencer Wildonger
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Robert A. Montgomery
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Neha A. Deshpande
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Abimereki D. Muzaale
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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Maziarz M, Chertow GM, Himmelfarb J, Hall YN. Homelessness and risk of end-stage renal disease. J Health Care Poor Underserved 2014; 25:1231-44. [PMID: 25130236 PMCID: PMC4285149 DOI: 10.1353/hpu.2014.0136] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
To identify homeless people with chronic kidney disease (CKD) who were at highest risk for end-stage renal disease (ESRD), we studied 982 homeless and 15,674 domiciled people with CKD receiving public health care. We developed four risk prediction models for the primary outcome of ESRD. Overall, 71 homeless and 888 domiciled people progressed to ESRD during follow-up (median: 6.6 years). Homeless people with CKD experienced significantly higher incidence rates of ESRD than poor but domiciled peers. Most homeless people who developed progressive CKD were readily identifiable well before ESRD using a prediction model with five common variables. We estimated that program following homeless people in the highest decile of ESRD risk would have captured 64-85% of those who eventually progressed to ESRD within five years. Thus, an approach targeting homeless people at high risk for ESRD appears feasible and could reduce substantial morbidity and costs incurred by this highly vulnerable group.
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26
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Kurella-Tamura M, Goldstein BA, Hall YN, Mitani AA, Winkelmayer WC. State medicaid coverage, ESRD incidence, and access to care. J Am Soc Nephrol 2014; 25:1321-9. [PMID: 24652791 DOI: 10.1681/asn.2013060658] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The proportion of low-income nonelderly adults covered by Medicaid varies widely by state. We sought to determine whether broader state Medicaid coverage, defined as the proportion of each state's low-income nonelderly adult population covered by Medicaid, associates with lower state-level incidence of ESRD and greater access to care. The main outcomes were incidence of ESRD and five indicators of access to care. We identified 408,535 adults aged 20-64 years, who developed ESRD between January 1, 2001, and December 31, 2008. Medicaid coverage among low-income nonelderly adults ranged from 12.2% to 66.0% (median 32.5%). For each additional 10% of the low-income nonelderly population covered by Medicaid, there was a 1.8% (95% confidence interval, 1.0% to 2.6%) decrease in ESRD incidence. Among nonelderly adults with ESRD, gaps in access to care between those with private insurance and those with Medicaid were narrower in states with broader coverage. For a 50-year-old white woman, the access gap to the kidney transplant waiting list between Medicaid and private insurance decreased by 7.7 percentage points in high (>45%) versus low (<25%) Medicaid coverage states. Similarly, the access gap to transplantation decreased by 4.0 percentage points and the access gap to peritoneal dialysis decreased by 3.8 percentage points in high Medicaid coverage states. In conclusion, states with broader Medicaid coverage had a lower incidence of ESRD and smaller insurance-related access gaps.
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Affiliation(s)
- Manjula Kurella-Tamura
- Geriatrics Research Education & Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; Division of Nephrology and
| | - Benjamin A Goldstein
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Palo Alto, California; and
| | - Yoshio N Hall
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington
| | - Aya A Mitani
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Palo Alto, California; and
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Purnell TS, Xu P, Leca N, Hall YN. Racial differences in determinants of live donor kidney transplantation in the United States. Am J Transplant 2013; 13:1557-65. [PMID: 23669021 PMCID: PMC4282921 DOI: 10.1111/ajt.12258] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 03/08/2013] [Accepted: 03/15/2013] [Indexed: 01/25/2023]
Abstract
Few studies have compared determinants of live donor kidney transplantation (LDKT) across all major US racial-ethnic groups. We compared determinants of racial-ethnic differences in LDKT among 208 736 patients who initiated treatment for end-stage kidney disease during 2005-2008. We performed proportional hazards and bootstrap analyses to estimate differences in LDKT attributable to sociodemographic and clinical factors. Mean LDKT rates were lowest among blacks (1.19 per 100 person-years [95% CI: 1.12-1.26]), American Indians/Alaska Natives-AI/ANs (1.40 [1.06-1.84]) and Pacific Islanders (1.10 [0.78-1.84]), intermediate among Hispanics (2.53 [2.39-2.67]) and Asians (3.89 [3.51-4.32]), and highest among whites (6.46 [6.31-6.61]). Compared with whites, the largest proportion of the disparity among blacks (20%) and AI/ANs (29%) was attributed to measures of predialysis care, while the largest proportion among Hispanics (14%) was attributed to health insurance coverage. Contextual poverty accounted for 16%, 4%, 18%, and 6% of the disparity among blacks, Hispanics, AI/ANs and Pacific Islanders but none of the disparity among Asians. In the United States, significant disparities in rates of LDKT persist, but determinants of these disparities vary by race-ethnicity. Efforts to expand preESKD insurance coverage, to improve access to high-quality predialysis care and to overcome socioeconomic barriers are important targets for addressing disparities in LDKT.
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Affiliation(s)
- T. S. Purnell
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD,Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD,Corresponding author: Tanjala S. Purnell,
| | - P. Xu
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, Washington
| | - N. Leca
- Kidney–Pancreas Transplant Section, Division of Nephrology, University of Washington, Seattle, WA
| | - Y. N. Hall
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, Washington
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28
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Whaley-Connell AT, Kurella Tamura M, Jurkovitz CT, Kosiborod M, McCullough PA. Advances in CKD detection and determination of prognosis: executive summary of the National Kidney Foundation-Kidney Early Evaluation Program (KEEP) 2012 annual data report. Am J Kidney Dis 2013; 61:S1-3. [PMID: 23507265 DOI: 10.1053/j.ajkd.2013.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 01/07/2013] [Indexed: 11/11/2022]
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29
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Jurkovitz CT, Li S, Norris KC, Saab G, Bomback AS, Whaley-Connell AT, McCullough PA. Association between lack of health insurance and risk of death and ESRD: results from the Kidney Early Evaluation Program (KEEP). Am J Kidney Dis 2013; 61:S24-32. [PMID: 23507267 PMCID: PMC3739048 DOI: 10.1053/j.ajkd.2012.12.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 12/19/2012] [Indexed: 01/27/2023]
Abstract
BACKGROUND Uninsured adults in the United States have poor access to health care services and worse health outcomes than insured adults. Little is known about the association between lack of insurance and chronic kidney disease (CKD) progression to end-stage renal disease (ESRD) or death in patients at high risk of kidney disease. We used 2000-2011 data from the National Kidney Foundation's Kidney Early Evaluation Program (KEEP) to examine this association. METHODS The study population included KEEP participants younger than 65 years. Outcomes were time to ESRD (chronic kidney failure treated by renal replacement therapy) and time to death. Incident ESRD was ascertained by linkage to the US Renal Data System, and vital status, by linkage to the Social Security Administration Death Master File. We used Cox proportional hazard regression to examine the association between insurance and risk of death or ESRD after adjusting for demographic variables. RESULTS Of 86,588 participants, 27.8% had no form of insurance, 10.3% had public insurance, and 61.9% had private insurance; 15.0% had CKD (defined as estimated glomerular filtration rate <60 mL/min/1.73 m(2) or urine albumin-creatinine ratio ≥ 30 mg/g), 63.3% had hypertension, and 27.7% had diabetes. Of participants with CKD, 29.3% had no health insurance. Participants without insurance were younger, more likely to be Hispanic and to have 12 or fewer years of education, and less likely to have seen a physician in the past year. After adjustment for demographic characteristics, uninsured KEEP participants were 82% more likely than privately insured participants to die (HR, 1.82; 95% CI, 1.56-2.12; P < 0.001) and 72% more likely to develop ESRD (HR, 1.72; 95% CI, 1.33-2.22; P < 0.001). The association between insurance and outcomes varied by CKD stage. CONCLUSIONS Lack of insurance is an independent risk factor for early death and ESRD in this population at high risk of kidney disease. Considering the high morbidity and mortality and increasing cost associated with ESRD, access to appropriate health insurance coverage is warranted.
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Affiliation(s)
- Claudine T Jurkovitz
- Christiana Care Center for Outcomes Research, Christiana Care Health System, Newark, DE 19718, USA.
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Purnell TS, Hall YN, Boulware LE. Understanding and overcoming barriers to living kidney donation among racial and ethnic minorities in the United States. Adv Chronic Kidney Dis 2012; 19:244-51. [PMID: 22732044 PMCID: PMC3385991 DOI: 10.1053/j.ackd.2012.01.008] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Revised: 01/27/2012] [Accepted: 01/30/2012] [Indexed: 01/04/2023]
Abstract
In the United States, racial-ethnic minorities experience disproportionately high rates of ESRD, but they are substantially less likely to receive living donor kidney transplants (LDKT) compared with their majority counterparts. Minorities may encounter barriers to LDKT at several steps along the path to receiving it, including consideration, pursuit, completion of LDKT, and the post-LDKT experience. These barriers operate at different levels related to potential recipients and donors, health care providers, health system structures, and communities. In this review, we present a conceptual framework describing various barriers that minorities face along the path to receiving LDKT. We also highlight promising recent and current initiatives to address these barriers, as well as gaps in initiatives, which may guide future interventions to reduce racial-ethnic disparities in LDKT.
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Affiliation(s)
- Tanjala S. Purnell
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD
- Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, Baltimore, MD
| | - Yoshio N. Hall
- Kidney Research Institute, Department of Medicine, University of Washington, Seattle, Washington
| | - L. Ebony Boulware
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD
- Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, Baltimore, MD
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Agrawal V, Jaar BG, Frisby XY, Chen SC, Qiu Y, Li S, Whaley-Connell AT, McCullough PA, Bomback AS. Access to health care among adults evaluated for CKD: findings from the Kidney Early Evaluation Program (KEEP). Am J Kidney Dis 2012; 59:S5-15. [PMID: 22339901 DOI: 10.1053/j.ajkd.2011.10.043] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 10/07/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND Data are scant regarding access to health care in patients with chronic kidney disease (CKD). We performed descriptive analyses using data from the National Kidney Foundation's Kidney Early Evaluation Program (KEEP), a nationwide health screening program for adults at high risk of CKD. METHODS From 2000-2010, a total of 122,502 adults without end-stage renal disease completed KEEP screenings; 27,927 (22.8%) met criteria for CKD (10,082, stages 1-2; 16,684, stage 3; and 1,161, stages 4-5). CKD awareness, self-rated health status, frequency of physician visits, difficulty obtaining medical care, types of caregivers, insurance status, and medication coverage and estimated costs were assessed. RESULTS Participants with CKD were more likely to report fair/poor health status than those without CKD. Health care utilization increased at later CKD stages; ~95% of participants at stages 3-5 had visited a physician during the preceding year compared with 83.7% of participants without CKD. More Hispanic and African American than white participants at all CKD stages reported not having a physician. Approximately 40% of participants younger than 65 years reported fair/poor health status at stages 4-5 compared with ~30% who were 65 years and older. Younger participants at all stages were more likely to report extreme or somewhat/moderate difficulty obtaining medical care. Comorbid conditions (diabetes, hypertension, and prior cardiovascular events) were associated with increased utilization of care. Utilization of nephrology care was poor at all CKD stages; <6% of participants at stage 3 and <30% at stages 4-5 reported ever seeing a nephrologist. CONCLUSIONS Lack of health insurance and perceived difficulty obtaining medical care with lower health care utilization, both of which are consistent with inadequate access to health care, are more likely for KEEP participants who are younger than 65 years, nonwhite, and without previously diagnosed comorbid conditions. Nephrology care is infrequent in elderly participants with advanced CKD who are nonwhite, have comorbid disease, and have high-risk states for cardiovascular disease.
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Affiliation(s)
- Varun Agrawal
- Division of Nephrology and Hypertension, Fletcher Allen Health Care, Burlington, VT 05401, USA.
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Fischer MJ, Go AS, Lora CM, Ackerson L, Cohan J, Kusek JW, Mercado A, Ojo A, Ricardo AC, Rosen LK, Tao K, Xie D, Feldman HI, Lash JP. CKD in Hispanics: Baseline characteristics from the CRIC (Chronic Renal Insufficiency Cohort) and Hispanic-CRIC Studies. Am J Kidney Dis 2011; 58:214-27. [PMID: 21705121 DOI: 10.1053/j.ajkd.2011.05.010] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Accepted: 05/09/2011] [Indexed: 01/13/2023]
Abstract
BACKGROUND Little is known regarding chronic kidney disease (CKD) in Hispanics. We compared baseline characteristics of Hispanic participants in the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic-CRIC (H-CRIC) Studies with non-Hispanic CRIC participants. STUDY DESIGN Cross-sectional analysis. SETTING & PARTICIPANTS Participants were aged 21-74 years with CKD using age-based estimated glomerular filtration rate (eGFR) at enrollment into the CRIC/H-CRIC Studies. H-CRIC included Hispanics recruited at the University of Illinois in 2005-2008, whereas CRIC included Hispanics and non-Hispanics recruited at 7 clinical centers in 2003-2007. FACTOR Race/ethnicity. OUTCOMES Blood pressure, angiotensin-converting enzyme (ACE)-inhibitor/angiotensin receptor blocker (ARB) use, and CKD-associated complications. MEASUREMENTS Demographic characteristics, laboratory data, blood pressure, and medications were assessed using standard techniques and protocols. RESULTS Of H-CRIC/CRIC participants, 497 were Hispanic, 1,650 were non-Hispanic black, and 1,638 were non-Hispanic white. Low income and educational attainment were nearly twice as prevalent in Hispanics compared with non-Hispanics (P < 0.01). Hispanics had self-reported diabetes (67%) more frequently than non-Hispanic blacks (51%) and whites (40%; P < 0.01). Blood pressure >130/80 mm Hg was more common in Hispanics (62%) than blacks (57%) and whites (35%; P < 0.05), and abnormalities in hematologic, metabolic, and bone metabolism parameters were more prevalent in Hispanics (P < 0.05), even after stratifying by entry eGFR. Hispanics had the lowest use of ACE inhibitors/ARBs among the high-risk subgroups, including participants with diabetes, proteinuria, and blood pressure >130/80 mm Hg. Mean eGFR was lower in Hispanics (39.6 mL/min/1.73 m(2)) than in blacks (43.7 mL/min/1.73 m(2)) and whites (46.2 mL/min/1.73 m(2)), whereas median proteinuria was higher in Hispanics (protein excretion, 0.72 g/d) than in blacks (0.24 g/d) and whites (0.12 g/d; P < 0.01). LIMITATIONS Generalizability; observed associations limited by residual bias and confounding. CONCLUSIONS Hispanics with CKD in the CRIC/H-CRIC Studies are disproportionately burdened with lower socioeconomic status, more frequent diabetes mellitus, less ACE-inhibitor/ARB use, worse blood pressure control, and more severe CKD and associated complications than their non-Hispanic counterparts.
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Current world literature. Curr Opin Pediatr 2010; 22:246-55. [PMID: 20299870 DOI: 10.1097/mop.0b013e32833846de] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Knauf F, Aronson PS. ESRD as a window into America's cost crisis in health care. J Am Soc Nephrol 2009; 20:2093-7. [PMID: 19729435 DOI: 10.1681/asn.2009070715] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Felix Knauf
- Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, TAC S-255, New Haven, CT 06520-8029, USA
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