1
|
Ishigami J, Jaar BG, Charleston JB, Lash JP, Brown J, Chen J, Mills KT, Taliercio JJ, Kansal S, Crews DC, Riekert KA, Dowdy DW, Appel LJ, Matsushita K. Factors Associated With Non-vaccination for Influenza Among Patients With CKD: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis 2024; 83:196-207.e1. [PMID: 37717847 PMCID: PMC10872850 DOI: 10.1053/j.ajkd.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/05/2023] [Accepted: 06/16/2023] [Indexed: 09/19/2023]
Abstract
RATIONALE & OBJECTIVE Vaccination for influenza is strongly recommended for people with chronic kidney disease (CKD) due to their immunocompromised state. Identifying risk factors for not receiving an influenza vaccine (non-vaccination) could inform strategies for improving vaccine uptake in this high-risk population. STUDY DESIGN Longitudinal observational study. SETTING & PARTICIPANTS 3,692 Chronic Renal Insufficiency Cohort Study (CRIC) participants. EXPOSURE Demographic factors, social determinants of health, clinical conditions, and health behaviors. OUTCOME Influenza non-vaccination, which was assessed based on a receipt of influenza vaccine ascertained during annual clinic visits in a subset of participants who were under nephrology care. ANALYTICAL APPROACH Mixed-effects Poisson models to estimate adjusted prevalence ratios (APRs). RESULTS Between 2009 and 2020, the pooled mean vaccine uptake was 72% (mean age, 66 years; 44% female; 44% Black race). In multivariable models, factors significantly associated with influenza non-vaccination were younger age (APR, 2.16 [95% CI, 1.85-2.52] for<50 vs≥75 years), Black race (APR, 1.58 [95% CI, 1.43-1.75] vs White race), lower education (APR, 1.20 [95% CI, 1.04-1.39 for less than high school vs college graduate]), lower annual household income (APR, 1.26 [95% CI, 1.06-1.49] for <$20,000 vs >$100,000), formerly married status (APR, 1.22 [95% CI, 1.09-1.35] vs currently married), and nonemployed status (APR, 1.13 [95% CI, 1.02-1.24] vs employed). In contrast, participants with diabetes (APR, 0.80 [95% CI, 0.73-0.87] vs no diabetes), chronic obstructive pulmonary disease (COPD) (APR, 0.80 [95% CI, 0.70-0.92] vs no COPD), end-stage kidney disease (APR, 0.64 [0.56 to 0.76] vs estimated glomerular filtration rate≥60mL/min/1.73m2), frailty (APR, 0.86 [95% CI, 0.74-0.99] vs no frailty), and ideal physical activity (APR, 0.90 [95% CI, 0.82-0.99] vs. physically inactive) were less likely to have non-vaccination status. LIMITATIONS Possible residual confounding. CONCLUSIONS Among adults with CKD receiving nephrology care, younger adults, Black individuals, and those with adverse social determinants of health were more likely to have the influenza non-vaccination status. Strategies are needed to address these disparities and reduce barriers to vaccination. PLAIN-LANGUAGE SUMMARY Identifying risk factors for not receiving an influenza vaccine ("non-vaccination") in people living with kidney disease, who are at risk of influenza and its complications, could inform strategies for improving vaccine uptake. In this study, we examined whether demographic factors, social determinants of health, and clinical conditions were linked to the status of not receiving an influenza vaccine among people living with kidney disease and receiving nephrology care. We found that younger adults, Black individuals, and those with adverse social determinants of health were more likely to not receive the influenza vaccine. These findings suggest the need for strategies to address these disparities and reduce barriers to vaccination in people living with kidney disease.
Collapse
Affiliation(s)
- Junichi Ishigami
- Department of Epidemiology, Bloomberg School of Public Health, School of Medicine, Johns Hopkins University, Baltimore, Maryland; Welch Center for Prevention, Epidemiology, and Clinical Research, School of Medicine, Johns Hopkins University, Baltimore, Maryland.
| | - Bernard G Jaar
- Department of Epidemiology, Bloomberg School of Public Health, School of Medicine, Johns Hopkins University, Baltimore, Maryland; Welch Center for Prevention, Epidemiology, and Clinical Research, School of Medicine, Johns Hopkins University, Baltimore, Maryland; Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jeanne B Charleston
- Department of Epidemiology, Bloomberg School of Public Health, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - James P Lash
- Division of Nephrology, College of Medicine, University of Illinois, Chicago, Illinois
| | - Julia Brown
- Division of Nephrology, College of Medicine, University of Illinois, Chicago, Illinois
| | - Jing Chen
- Division of Nephrology, School of Medicine, Tulane University New Orleans, Louisiana
| | - Katherine T Mills
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University New Orleans, Louisiana
| | | | - Sheru Kansal
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Deidra C Crews
- Welch Center for Prevention, Epidemiology, and Clinical Research, School of Medicine, Johns Hopkins University, Baltimore, Maryland; Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Kristin A Riekert
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David W Dowdy
- Department of Epidemiology, Bloomberg School of Public Health, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Lawrence J Appel
- Department of Epidemiology, Bloomberg School of Public Health, School of Medicine, Johns Hopkins University, Baltimore, Maryland; Welch Center for Prevention, Epidemiology, and Clinical Research, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Kunihiro Matsushita
- Department of Epidemiology, Bloomberg School of Public Health, School of Medicine, Johns Hopkins University, Baltimore, Maryland; Welch Center for Prevention, Epidemiology, and Clinical Research, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
2
|
Morenz AM, Staloff J, Liao JM, Wong ES. Use of New Audio-Only Telemedicine Claim Modifiers. JAMA Netw Open 2023; 6:e2348224. [PMID: 38109111 PMCID: PMC10728765 DOI: 10.1001/jamanetworkopen.2023.48224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/29/2023] [Indexed: 12/19/2023] Open
Abstract
Importance Policymakers at both the state and federal levels face decisions about coverage of audio-only telemedicine amid a dearth of reliable data due to changes and variation in billing practices. Objective To describe early trends in the use of new audio-only telemedicine claims modifiers 93 and FQ in Washington State, which were introduced to improve the designation and identification of audio-only telemedicine claims. Design, Setting, and Participants This retrospective cohort study analyzed claims data from the Washington All-Payer Claims Database from January to November 2022. Participants included 4.3 million children and adults insured for at least 6 months in 2021 through public or private insurance plans. Exposures Use of audio-only telemedicine was compared by age, race, ethnicity, insurance type, rurality, and Social Vulnerability Index. Main Outcomes and Measures Audio-only telemedicine services were identified by claims appended by Current Procedural Terminology (CPT) code modifiers 93 or FQ or that included telephone-only CPT codes. Modifiers 93 and FQ denote audio-only telemedicine services for any reason and for behavioral health concerns, respectively. Results In 2022, there were a total of 917 589 audio-only telemedicine services, of which 345 941 (38%) were appended with modifier FQ and 55 352 (6%) with modifier 93. Audio-only telemedicine services with these modifiers were most frequent for behavioral health diagnoses or routine prenatal and postpartum care. Individuals who used telemedicine exclusively via audio-only modality were more likely to be older (mean [SD] age, 46.0 [22.5] vs 42.0 [21.4] years) and insured by Medicare (41 758 of 196 225 [21%] vs 95 962 of 707 626 [14%]) than those who used at least 1 audiovisual service. Conclusions and Relevance In this cohort study of a statewide all-payer claims database, modifiers 93 and FQ offered the important capability to identify audio-only telemedicine services beyond telephone-only CPT codes, but their uptake remained low. Audio-only telemedicine appears to offer an important means for access to behavioral health and perinatal care access, but further work is needed to study outcomes and quality of care.
Collapse
Affiliation(s)
- Anna M. Morenz
- Department of Medicine, University of Washington, Seattle
- Value and Systems Science Lab, University of Washington, Seattle
| | - Jonathan Staloff
- Value and Systems Science Lab, University of Washington, Seattle
- Department of Family Medicine, University of Washington, Seattle
| | - Joshua M. Liao
- Department of Medicine, University of Washington, Seattle
- Value and Systems Science Lab, University of Washington, Seattle
| | - Edwin S. Wong
- Value and Systems Science Lab, University of Washington, Seattle
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle
| |
Collapse
|
3
|
Williams P. Retaining Race in Chronic Kidney Disease Diagnosis and Treatment. Cureus 2023; 15:e45054. [PMID: 37701164 PMCID: PMC10495104 DOI: 10.7759/cureus.45054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 09/14/2023] Open
Abstract
The best overall measure of kidney function is glomerular filtration rate (GFR) as commonly estimated from serum creatinine concentrations (eGFRcr) using formulas that correct for the higher average creatinine concentrations in Blacks. After two decades of use, these formulas have come under scrutiny for estimating GFR differently in Blacks and non-Blacks. Discussions of whether to include race (Black vs. non-Black) in the calculation of eGFRcr fail to acknowledge that the original race-based eGFRcr provided the same CKD treatment recommendations for Blacks and non-Blacks based on directly (exogenously) measured GFR. Nevertheless, the National Kidney Foundation and the American Society of Nephrology Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease removed race in CKD treatment guidelines and pushed for the immediate adoption of a race-free eGFRcr formula by physicians and clinical laboratories. This formula is projected to negate CKD in 5.51 million White and other non-Black adults and reclassify CKD to less severe stages in another 4.59 million non-Blacks, in order to expand treatment eligibility to 434,000 Blacks not previously diagnosed and to 584,000 Blacks previously diagnosed with less severe CKD. This review examines: 1) the validity of the arguments for removing the original race correction, and 2) the performance of the proposed replacement formula. Excluding race in the derivation of eGFRcr changed the statistical bias from +3.7 to -3.6 ml/min/1.73m2 in Blacks and from +0.5 to +3.9 in non-Blacks, i.e., promoting CKD diagnosis in Blacks at the cost of restricting diagnosis in non-Blacks. By doing so, the revised eGFRcr greatly exaggerates the purported racial disparity in CKD burden. Claims that the revised formulas identify heretofore undiagnosed CKD in Blacks are not supported when studies that used kidney failure replacement therapy and mortality are interpreted as proxies for baseline CKD. Alternatively, a race-stratified eGFRcr (i.e., separate equations for Blacks and non-Blacks) would provide the least biased eGFRcr for both Blacks and non-Blacks and the best medical treatment for all patients.
Collapse
Affiliation(s)
- Paul Williams
- Life Sciences, Lawrence Berkeley National Laboratory, Berkeley, USA
| |
Collapse
|
4
|
Eadon MT, Cavanaugh KL, Orlando LA, Christian D, Chakraborty H, Steen-Burrell KA, Merrill P, Seo J, Hauser D, Singh R, Beasley CM, Fuloria J, Kitzman H, Parker AS, Ramos M, Ong HH, Elwood EN, Lynch SE, Clermont S, Cicali EJ, Starostik P, Pratt VM, Nguyen KA, Rosenman MB, Calman NS, Robinson M, Nadkarni GN, Madden EB, Kucher N, Volpi S, Dexter PR, Skaar TC, Johnson JA, Cooper-DeHoff RM, Horowitz CR. Design and rationale of GUARDD-US: A pragmatic, randomized trial of genetic testing for APOL1 and pharmacogenomic predictors of antihypertensive efficacy in patients with hypertension. Contemp Clin Trials 2022; 119:106813. [PMID: 35660539 PMCID: PMC9928488 DOI: 10.1016/j.cct.2022.106813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/25/2022] [Accepted: 05/30/2022] [Indexed: 11/28/2022]
Abstract
RATIONALE AND OBJECTIVE APOL1 risk alleles are associated with increased cardiovascular and chronic kidney disease (CKD) risk. It is unknown whether knowledge of APOL1 risk status motivates patients and providers to attain recommended blood pressure (BP) targets to reduce cardiovascular disease. STUDY DESIGN Multicenter, pragmatic, randomized controlled clinical trial. SETTING AND PARTICIPANTS 6650 individuals with African ancestry and hypertension from 13 health systems. INTERVENTION APOL1 genotyping with clinical decision support (CDS) results are returned to participants and providers immediately (intervention) or at 6 months (control). A subset of participants are re-randomized to pharmacogenomic testing for relevant antihypertensive medications (pharmacogenomic sub-study). CDS alerts encourage appropriate CKD screening and antihypertensive agent use. OUTCOMES Blood pressure and surveys are assessed at baseline, 3 and 6 months. The primary outcome is change in systolic BP from enrollment to 3 months in individuals with two APOL1 risk alleles. Secondary outcomes include new diagnoses of CKD, systolic blood pressure at 6 months, diastolic BP, and survey results. The pharmacogenomic sub-study will evaluate the relationship of pharmacogenomic genotype and change in systolic BP between baseline and 3 months. RESULTS To date, the trial has enrolled 3423 participants. CONCLUSIONS The effect of patient and provider knowledge of APOL1 genotype on systolic blood pressure has not been well-studied. GUARDD-US addresses whether blood pressure improves when patients and providers have this information. GUARDD-US provides a CDS framework for primary care and specialty clinics to incorporate APOL1 genetic risk and pharmacogenomic prescribing in the electronic health record. TRIAL REGISTRATION ClinicalTrials.govNCT04191824.
Collapse
Affiliation(s)
- Michael T Eadon
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | | | - Lori A Orlando
- Duke University School of Medicine, Durham, NC 27720, USA
| | - David Christian
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Hrishikesh Chakraborty
- Duke University School of Medicine, Durham, NC 27720, USA; Duke Clinical Research Institute, Durham, NC 27720, USA
| | | | - Peter Merrill
- Duke Clinical Research Institute, Durham, NC 27720, USA
| | - Janet Seo
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Diane Hauser
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Institute for Family Health, New York, NY 10029, USA
| | - Rajbir Singh
- Meharry Medical College, Nashville, TN 37208, USA
| | - Cherry Maynor Beasley
- McKenzie-Elliott School of Nursing, University of North Carolina at Pembroke, Pembroke, NC 28372, USA
| | - Jyotsna Fuloria
- Office of Research, University Medical Center New Orleans, New Orleans, LA 70112, USA
| | - Heather Kitzman
- Baylor Scott & White Health, Baylor University, Robbins Institute for Health Policy & Leadership, Dallas, TX 75246, USA
| | - Alexander S Parker
- University of Florida College of Medicine - Jacksonville, Jacksonville, FL 32209, USA
| | - Michelle Ramos
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Henry H Ong
- Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Erica N Elwood
- University of Florida, College of Pharmacy, Gainesville, FL 32610, USA
| | - Sheryl E Lynch
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Sabrina Clermont
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Emily J Cicali
- University of Florida, College of Pharmacy, Gainesville, FL 32610, USA
| | - Petr Starostik
- University of Florida, College of Medicine, Gainesville, FL 32610, USA
| | - Victoria M Pratt
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Khoa A Nguyen
- University of Florida, College of Pharmacy, Gainesville, FL 32610, USA
| | - Marc B Rosenman
- Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Neil S Calman
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Institute for Family Health, New York, NY 10029, USA
| | | | - Girish N Nadkarni
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Ebony B Madden
- Division of Genomic Medicine, National Human Genome Research Institute, Bethesda, MD 20892, USA
| | - Natalie Kucher
- Division of Genomic Medicine, National Human Genome Research Institute, Bethesda, MD 20892, USA
| | - Simona Volpi
- Division of Genomic Medicine, National Human Genome Research Institute, Bethesda, MD 20892, USA
| | - Paul R Dexter
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Todd C Skaar
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Julie A Johnson
- University of Florida, College of Pharmacy, Gainesville, FL 32610, USA
| | | | - Carol R Horowitz
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| |
Collapse
|
5
|
Chu CD, Powe NR, McCulloch CE, Crews DC, Han Y, Bragg-Gresham JL, Saran R, Koyama A, Burrows NR, Tuot DS. Trends in Chronic Kidney Disease Care in the US by Race and Ethnicity, 2012-2019. JAMA Netw Open 2021; 4:e2127014. [PMID: 34570204 PMCID: PMC8477264 DOI: 10.1001/jamanetworkopen.2021.27014] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/25/2021] [Indexed: 12/13/2022] Open
Abstract
Importance Significant racial and ethnic disparities in chronic kidney disease (CKD) progression and outcomes are well documented, as is low use of guideline-recommended CKD care. Objective To examine guideline-recommended CKD care delivery by race and ethnicity in a large, diverse population. Design, Setting, and Participants In this serial cross-sectional study, adult patients with CKD that did not require dialysis, defined as a persistent estimated glomerular filtration rate less than 60 mL/min/1.73 m2 or a urine albumin-creatinine ratio of 30 mg/g or higher for at least 90 days, were identified in 2-year cross-sections from January 1, 2012, to December 31, 2019. Data from the OptumLabs Data Warehouse, a national data set of administrative and electronic health record data for commercially insured and Medicare Advantage patients, were used. Exposures The independent variables were race and ethnicity, as reported in linked electronic health records. Main Outcomes and Measures On the basis of guideline-recommended CKD care, the study examined care delivery process measures (angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker prescription for albuminuria, statin prescription, albuminuria testing, nephrology care for CKD stage 4 or higher, and avoidance of chronic nonsteroidal anti-inflammatory drug prescription) and care delivery outcome measures (blood pressure and diabetes control). Results A total of 452 238 patients met the inclusion criteria (mean [SD] age, 74.0 [10.2] years; 262 089 [58.0%] female; a total of 7573 [1.7%] Asian, 49 970 [11.0%] Black, 15 540 [3.4%] Hispanic, and 379 155 [83.8%] White). Performance on process measures was higher among Asian, Black, and Hispanic patients compared with White patients for angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use (79.8% for Asian patients, 76.7% for Black patients, and 79.9% for Hispanic patients compared with 72.3% for White patients in 2018-2019), statin use (72.6% for Asian patients, 69.1% for Black patients, and 74.1% for Hispanic patients compared with 61.5% for White patients), nephrology care (64.8% for Asian patients, 72.9% for Black patients, and 69.4% for Hispanic patients compared with 58.3% for White patients), and albuminuria testing (53.9% for Asian patients, 41.0% for Black patients, and 52.6% for Hispanic patients compared with 30.7% for White patients). Achievement of blood pressure control to less than 140/90 mm Hg was similar or lower among Asian (71.8%), Black (63.3%), and Hispanic (69.8%) patients compared with White patients (72.9%). Achievement of diabetes control with hemoglobin A1c less than 7.0% was 50.1% in Asian patients, 49.3% in Black patients, and 46.0% in Hispanic patients compared with 50.3% for White patients. Conclusions and Relevance Higher performance on CKD care process measures among Asian, Black, and Hispanic patients suggests that differences in medication prescription and diagnostic testing are unlikely to fully explain known disparities in CKD progression and kidney failure. Improving care delivery processes alone may be inadequate for reducing these disparities.
Collapse
Affiliation(s)
- Chi D. Chu
- Division of Nephrology, University of California, San Francisco
- OptumLabs Visiting Fellow, OptumLabs, Eden Prairie, Minnesota
| | - Neil R. Powe
- Department of Medicine, University of California, San Francisco
- Department of Medicine, Mark Zuckerberg and Priscilla Chan San Francisco General Hospital, San Francisco, California
- Center for Vulnerable Populations, University of California, San Francisco
| | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Deidra C. Crews
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Yun Han
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
| | | | - Rajiv Saran
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor
| | - Alain Koyama
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nilka R. Burrows
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Delphine S. Tuot
- Division of Nephrology, University of California, San Francisco
- Department of Medicine, University of California, San Francisco
- Department of Medicine, Mark Zuckerberg and Priscilla Chan San Francisco General Hospital, San Francisco, California
- Center for Vulnerable Populations, University of California, San Francisco
| |
Collapse
|
6
|
Gerber C, Cai X, Lee J, Craven T, Scialla J, Souma N, Srivastava A, Mehta R, Paluch A, Hodakowski A, Frazier R, Carnethon MR, Wolf MS, Isakova T. Incidence and Progression of Chronic Kidney Disease in Black and White Individuals with Type 2 Diabetes. Clin J Am Soc Nephrol 2018; 13:884-892. [PMID: 29798889 PMCID: PMC5989671 DOI: 10.2215/cjn.11871017] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 03/01/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Type 2 diabetes and associated CKD disproportionately affect blacks. It is uncertain if racial disparities in type 2 diabetes-associated CKD are driven by biologic factors that influence propensity to CKD or by differences in type 2 diabetes care. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a post hoc analysis of 1937 black and 6372 white participants of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial to examine associations of black race with change in eGFR and risks of developing microalbuminuria, macroalbuminuria, incident CKD (eGFR<60 ml/min per 1.73m2, ≥25% decrease from baseline eGFR, and eGFR slope <-1.6 ml/min per 1.73 m2 per year), and kidney failure or serum creatinine >3.3 mg/dl. RESULTS During a median follow-up that ranged between 4.4 and 4.7 years, 278 black participants (58 per 1000 person-years) and 981 white participants (55 per 1000 person-years) developed microalbuminuria, 122 black participants (16 per 1000 person-years) and 374 white participants (14 per 1000 person-years) developed macroalbuminuria, 111 black participants (21 per 1000 person-years) and 499 white participants (28 per 1000 person-years) developed incident CKD, and 59 black participants (seven per 1000 person-years) and 178 white participants (six per 1000 person-years) developed kidney failure or serum creatinine >3.3 mg/dl. Compared with white participants, black participants had lower risks of incident CKD (hazard ratio, 0.73; 95% confidence intervals, 0.57 to 0.92). There were no significant differences by race in eGFR decline or in risks of microalbuminuria, macroalbuminuria, and kidney failure or of serum creatinine >3.3 mg/dl. CONCLUSIONS Black participants enrolled in a randomized controlled trial had lower rates of incident CKD compared with white participants. Rates of eGFR decline, microalbuminuria, macroalbuminuria, and kidney failure did not vary by race.
Collapse
Affiliation(s)
- Claire Gerber
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine
- Division of Nephrology and Hypertension, Department of Medicine, and
| | - Xuan Cai
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine
| | - Jungwha Lee
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine
| | - Timothy Craven
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina; and
| | - Julia Scialla
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Duke University, Durham, North Carolina
| | - Nao Souma
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine
- Division of Nephrology and Hypertension, Department of Medicine, and
| | - Rupal Mehta
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine
- Division of Nephrology and Hypertension, Department of Medicine, and
| | - Amanda Paluch
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Alexander Hodakowski
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine
| | - Rebecca Frazier
- Division of Nephrology and Hypertension, Department of Medicine, and
| | - Mercedes R. Carnethon
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Myles Selig Wolf
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Duke University, Durham, North Carolina
| | - Tamara Isakova
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine
- Division of Nephrology and Hypertension, Department of Medicine, and
| |
Collapse
|
7
|
Crowley ST, Murphy K. Delivering a "New Deal" of Kidney Health Opportunities to Improve Outcomes Within the Veterans Health Administration. Am J Kidney Dis 2018; 72:444-450. [PMID: 29627134 DOI: 10.1053/j.ajkd.2018.01.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 01/22/2018] [Indexed: 11/11/2022]
Abstract
Just as the "New Deal" aimed to elevate the "forgotten man" of the Great Depression through governmental relief and reform, so does the Department of Veterans Affairs (VA) health care system aim to improve the health of veterans with the invisible illness of chronic kidney disease through a concerted series of health care delivery reforms. Augmenting its primary care platform with advances in informatics and health service delivery initiatives targeting kidney disease, the VA is changing how nephrology care is provided to veterans with the goal of optimized population kidney health. As the largest provider of kidney health services in the country, the VA offers an instructive case study of the value of comprehensive health care coverage for people with chronic kidney disease. Recent reports of kidney health outcomes among veterans support the benefit of the VA's integrated health care delivery system. Suggestions to optimize veterans' kidney health further may be equally applicable to other health systems caring for people afflicted with kidney disease.
Collapse
Affiliation(s)
- Susan T Crowley
- Veterans Health Administration, Specialty Care Services/Office of Policy and Services, West Haven, CT; Section of Nephrology, Department of Medicine, Yale University School of Medicine, West Haven, CT.
| | - Katherine Murphy
- Veterans Health Administration, Specialty Care Services/Office of Policy and Services, West Haven, CT
| |
Collapse
|
8
|
Horowitz CR, Ferryman K, Negron R, Sabin T, Rodriguez M, Zinberg RF, Böttinger E, Robinson M. Race, Genomics and Chronic Disease: What Patients with African Ancestry Have to Say. J Health Care Poor Underserved 2018; 28:248-260. [PMID: 28238999 DOI: 10.1353/hpu.2017.0020] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Variants of the APOL1 gene increase risk for kidney failure 10-fold, and are nearly exclusively found in people with African ancestry. To translate genomic discoveries into practice, we gathered information about effects and challenges incorporating genetic risk in clinical care. METHODS An academic-community-clinical team tested 26 adults with self-reported African ancestry for APOL1 variants, conducting in-depth interviews about patients' beliefs and attitudes toward genetic testing- before, immediately, and 30 days after receiving test results. We used constant comparative analysis of interview transcripts to identify themes. RESULTS Themes included: Knowledge of genetic risk for kidney failure may motivate providers and patients to take hypertension more seriously, rather than inspiring fatalism or anxiety. Having genetic risk for a disease may counter stereotypes of Blacks as non-adherent or low-literate, rather than exacerbate stereotypes. CONCLUSION Populations most likely to benefit from genomic research can inform strategies for genetic testing and future research.
Collapse
|
9
|
Harding K, Mersha TB, Webb FA, Vassalotti JA, Nicholas SB. Current State and Future Trends to Optimize the Care of African Americans with End-Stage Renal Disease. Am J Nephrol 2017; 46:156-164. [PMID: 28787724 DOI: 10.1159/000479479] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Chronic kidney disease is a progressive disease, which terminates in end-stage renal diseases (ESRD) that requires either dialysis or kidney transplantation for the patient to survive. There is an alarming trend in the disparities of ESRD in African Americans (AAs). Currently, AAs represent more than 30% of incident ESRD cases, yet they constitute 15% of the overall US population. Despite the reductions in mortality, increases in access to patient-centered home dialysis and preemptive kidney transplantation for the overall US ESRD population over the last decade, disparities in the care of AAs with ESRD remain largely unaffected. SUMMARY This review discusses patient-, community-, and practitioner-related factors that contribute to disparities in ESRD care for AAs. In particular, the review addresses issues related to end-of-life support, the importance of Apolipoprotein-1 gene variants, and the advent of pharmacogenomics toward achieving precision care. The need for accessible clinical intelligence for the ESRD population is discussed. Several interventions and a call to action to address the disparities are presented. Key Messages: Significant disparities in ESRD care exist for AAs. Strategies to enhance patient engagement, education, accountable partnerships, and clinical intelligence may reduce these disparities.
Collapse
|
10
|
Jahantigh FF, Malmir B, Avilaq BA. A computer-aided diagnostic system for kidney disease. Kidney Res Clin Pract 2017; 36:29-38. [PMID: 28392995 PMCID: PMC5331973 DOI: 10.23876/j.krcp.2017.36.1.29] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 09/04/2016] [Accepted: 10/04/2016] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Disease diagnosis is complicated since patients may demonstrate similar symptoms but physician may diagnose different diseases. There are a few number of investigations aimed to create a fuzzy expert system, as a computer aided system for disease diagnosis. METHODS In this research, a cross-sectional descriptive study conducted in a kidney clinic in Tehran, Iran in 2012. Medical diagnosis fuzzy rules applied, and a set of symptoms related to the set of considered diseases defined. The input case to be diagnosed defined by assigning a fuzzy value to each symptom and then three physicians asked about each suspected diseases. Then comments of those three physicians summarized for each disease. The fuzzy inference applied to obtain a decision fuzzy set for each disease, and crisp decision values attained to determine the certainty of existence for each disease. RESULTS Results indicated that, in the diagnosis of seven cases of kidney disease by examining 21 indicators using fuzzy expert system, kidney stone disease with 63% certainty was the most probable, renal tubular was at the lowest level with 15%, and other kidney diseases were at the other levels. The most remarkable finding of this study was that results of kidney disease diagnosis (e.g., kidney stone) via fuzzy expert system were fully compatible with those of kidney physicians. CONCLUSION The proposed fuzzy expert system is a valid, reliable, and flexible instrument to diagnose several typical input cases. The developed system decreases the effort of initial physical checking and manual feeding of input symptoms.
Collapse
Affiliation(s)
| | - Behnam Malmir
- Department of Industrial and Manufacturing Systems Engineering, Kansas State University, Manhattan, KS, USA
| | - Behzad Aslani Avilaq
- Department of Management Engineering, Istanbul Technical University, Istanbul, Turkey
| |
Collapse
|
11
|
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: 2063] [Impact Index Per Article: 294.7] [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.
Collapse
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
| |
Collapse
|
12
|
Norris KC, Mensah GA, Boulware LE, Lu JL, Ma JZ, Streja E, Molnar MZ, Kalantar-Zadeh K, Kovesdy CP. Age, Race and Cardiovascular Outcomes in African American Veterans. Ethn Dis 2016; 26:305-14. [PMID: 27440969 DOI: 10.18865/ed.26.3.305] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND In the general population, compared wtih their White peers, African Americans suffer premature all-cause and cardiovascular (CV) deaths, attributed in part to reduced access to care and lower socioeconomic status. Prior reports indicated younger (aged 35 to 44 years) African Americans had a signficantly greater age-adjusted risk of death. Recent studies suggest that in a more egalitarian health care structure than typical United States (US) health care structures, African Americans may have similar or even better CV outcomes, but the impact of age is less well-known. METHODS We examined age stratified all-cause mortality, and incident coronary heart disease (CHD) and ischemic stroke in 3,072,966 patients (547,441 African American and 2,525,525 White) with an estimated glomerular filtration rate (eGFR)>60 mL/min/1.73m(2) receiving care from the US Veterans Health Administration. Outcomes were examined in Cox models adjusted for demographics, comorbidities, kidney function, blood pressure, socioeconomics and indicators of the quality of health care delivery. RESULTS African Americans had an overall 30% lower all-cause mortality (P<.001) and 29% lower incidence of CHD (P<.001) and higher incidence of ischemic stroke (aHR, 95%CI: 1.16, 1.13-1.18, P<.001). The lower rates of mortality and CHD were strongest in younger African Americans and attenuated across patients aged ≥70 years. Stroke rates did not differ by race in persons aged <70 years. CONCLUSIONS Among patients with normal eGFR and receiving care in the Veterans Health Administration, younger African Americans had lower all-cause mortality and incidence of CHD and similar rates of stroke, independent of demographic, comorbidity and socioeconomic differences. The lower all-cause mortality persisted but attenuated with increasing age and the lower incidence of CHD ended at aged ≥80 years. The higher incidence of ischemic stroke in African Americans was driven by increasing risk in patients aged ≥70 years suggesting that the improved cardiovascular outcomes were most dramatic for younger African Americans.
Collapse
Affiliation(s)
- Keith C Norris
- David Geffen School of Medicine; University of California, Los Angeles
| | - George A Mensah
- National Heart, Lung, and Blood Institute, National Institutes of Health
| | | | - Jun L Lu
- University of Tennessee Heath Science Center
| | | | | | | | | | - Csaba P Kovesdy
- University of Tennessee Heath Science Center; Memphis VA Medical Center
| |
Collapse
|
13
|
Horowitz CR, Abul-Husn NS, Ellis S, Ramos MA, Negron R, Suprun M, Zinberg RE, Sabin T, Hauser D, Calman N, Bagiella E, Bottinger EP. Determining the effects and challenges of incorporating genetic testing into primary care management of hypertensive patients with African ancestry. Contemp Clin Trials 2016; 47:101-8. [PMID: 26747051 PMCID: PMC4818169 DOI: 10.1016/j.cct.2015.12.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 12/21/2015] [Accepted: 12/28/2015] [Indexed: 12/11/2022]
Abstract
People of African ancestry (Blacks) have increased risk of kidney failure due to numerous socioeconomic, environmental, and clinical factors. Two variants in the APOL1 gene are now thought to account for much of the racial disparity associated with hypertensive kidney failure in Blacks. However, this knowledge has not been translated into clinical care to help improve patient outcomes and address disparities. GUARDD is a randomized trial to evaluate the effects and challenges of incorporating genetic risk information into primary care. Hypertensive, non-diabetic, adults with self-reported African ancestry, without kidney dysfunction, are recruited from diverse clinical settings and randomized to undergo APOL1 genetic testing at baseline (intervention) or at one year (waitlist control). Providers are educated about genomics and APOL1. Guided by a genetic counselor, trained staff return APOL1 results to patients and provide low-literacy educational materials. Real-time clinical decision support tools alert clinicians of their patients' APOL1 results and associated risk status at the point of care. Our academic-community-clinical partnership designed a study to generate information about the impact of genetic risk information on patient care (blood pressure and renal surveillance) and on patient and provider knowledge, attitudes, beliefs, and behaviors. GUARDD will help establish the effective implementation of APOL1 risk-informed management of hypertensive patients at high risk of CKD, and will provide a robust framework for future endeavors to implement genomic medicine in diverse clinical practices. It will also add to the important dialog about factors that contribute to and may help eliminate racial disparities in kidney disease.
Collapse
Affiliation(s)
- C R Horowitz
- Department of Population Health Sciences and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY 10029, USA; Center for Health Equity and Community Engaged Research, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, 10029, USA; The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 18th Floor, Room 18-16, New York, NY 10029, USA.
| | - N S Abul-Husn
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 18th Floor, Room 18-16, New York, NY 10029, USA; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1022, New York, NY 10029, USA.
| | - S Ellis
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 18th Floor, Room 18-16, New York, NY 10029, USA.
| | - M A Ramos
- Department of Population Health Sciences and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY 10029, USA; Center for Health Equity and Community Engaged Research, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, 10029, USA.
| | - R Negron
- Yale Institute for Network Science, Yale University, 17 Hillhouse Avenue, P.O. Box 208263, New Haven, CT 06520, USA.
| | - M Suprun
- Department of Population Health Sciences and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY 10029, USA.
| | - R E Zinberg
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1022, New York, NY 10029, USA.
| | - T Sabin
- Department of Population Health Sciences and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY 10029, USA.
| | - D Hauser
- Institute for Family Health, 16 East 16th Street, New York, NY 10003, USA.
| | - N Calman
- Center for Health Equity and Community Engaged Research, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, 10029, USA; Institute for Family Health, 16 East 16th Street, New York, NY 10003, USA.
| | - E Bagiella
- Department of Population Health Sciences and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY 10029, USA.
| | - E P Bottinger
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Annenberg Building, 18th Floor, Room 18-16, New York, NY 10029, USA; Berlin Institute of Health, Berlin, Germany.
| |
Collapse
|
14
|
Norton J. Health Disparities in Chronic Kidney Disease. PHYSICIAN ASSISTANT CLINICS 2016. [DOI: 10.1016/j.cpha.2015.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
15
|
Assari S. Racial disparities in chronic kidney diseases in the United States; a pressing public health challenge with social, behavioral and medical causes. J Nephropharmacol 2015; 5:4-6. [PMID: 28197489 PMCID: PMC5297505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 12/05/2015] [Indexed: 12/02/2022] Open
Affiliation(s)
- Shervin Assari
- 1Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
,2Center for Research on Ethnicity, Culture and Health, School of Public Health, University of Michigan, Ann Arbor, MI, USA
,Corresponding author: Shervin Assari, 4250 Plymouth Rd, Ann Arbor, MI 48109. Phone: 734-232-0445; Fax: 734-615-8739;
| |
Collapse
|
16
|
Kovesdy CP, Norris KC, Boulware LE, Lu JL, Ma JZ, Streja E, Molnar MZ, Kalantar-Zadeh K. Association of Race With Mortality and Cardiovascular Events in a Large Cohort of US Veterans. Circulation 2015; 132:1538-48. [PMID: 26384521 PMCID: PMC4618085 DOI: 10.1161/circulationaha.114.015124] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Accepted: 08/10/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND In the general population, blacks experience higher mortality than their white peers, attributed in part to their lower socioeconomic status, reduced access to care, and possibly intrinsic biological factors. Patients with kidney disease are a notable exception, among whom blacks experience lower mortality. It is unclear if similar differences affecting outcomes exist in patients with no kidney disease but with equal or similar access to health care. METHODS AND RESULTS We compared all-cause mortality, incident coronary heart disease, and incident ischemic stroke using multivariable-adjusted Cox models in a nationwide cohort of 547 441 black and 2 525 525 white patients with baseline estimated glomerular filtration rate ≥ 60 mL·min⁻¹·1.73 m⁻² receiving care from the US Veterans Health Administration. In parallel analyses, we compared outcomes in black versus white individuals in the National Health and Nutrition Examination Survey (NHANES) 1999 to 2004. After multivariable adjustments in veterans, black race was associated with 24% lower all-cause mortality (adjusted hazard ratio, 0.76; 95% confidence interval, 0.75-0.77; P<0.001) and 37% lower incidence of coronary heart disease (adjusted hazard ratio, 0.63; 95% confidence interval, 0.62-0.65; P<0.001) but a similar incidence of ischemic stroke (adjusted hazard ratio, 0.99; 95% confidence interval, 0.97-1.01; P=0.3). Black race was associated with a 42% higher adjusted mortality among individuals with estimated glomerular filtration rate ≥ 60 mL·min⁻¹·1.73 m⁻² in NHANES (adjusted hazard ratio, 1.42; 95% confidence interval, 1.09-1.87). CONCLUSIONS Black veterans with normal estimated glomerular filtration rate and equal access to healthcare have lower all-cause mortality and incidence of coronary heart disease and a similar incidence of ischemic stroke. These associations are in contrast to the higher mortality experienced by black individuals in the general US population.
Collapse
Affiliation(s)
- Csaba P Kovesdy
- From Nephrology Section, Memphis VA Medical Center, TN (C.P.K.); Division of Nephrology, University of Tennessee Health Science Center, Memphis (C.P.K., J.L.L., M.Z.M.); Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA (K.C.N.); Department of Medicine, Duke University, Durham, NC (L.E.B.); Department of Public Health Sciences and Division of Nephrology, Department of Medicine, University of Virginia, Charlottesville (J.Z.M.); and Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange (E.S., K.K.-Z.).
| | - Keith C Norris
- From Nephrology Section, Memphis VA Medical Center, TN (C.P.K.); Division of Nephrology, University of Tennessee Health Science Center, Memphis (C.P.K., J.L.L., M.Z.M.); Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA (K.C.N.); Department of Medicine, Duke University, Durham, NC (L.E.B.); Department of Public Health Sciences and Division of Nephrology, Department of Medicine, University of Virginia, Charlottesville (J.Z.M.); and Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange (E.S., K.K.-Z.)
| | - L Ebony Boulware
- From Nephrology Section, Memphis VA Medical Center, TN (C.P.K.); Division of Nephrology, University of Tennessee Health Science Center, Memphis (C.P.K., J.L.L., M.Z.M.); Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA (K.C.N.); Department of Medicine, Duke University, Durham, NC (L.E.B.); Department of Public Health Sciences and Division of Nephrology, Department of Medicine, University of Virginia, Charlottesville (J.Z.M.); and Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange (E.S., K.K.-Z.)
| | - Jun L Lu
- From Nephrology Section, Memphis VA Medical Center, TN (C.P.K.); Division of Nephrology, University of Tennessee Health Science Center, Memphis (C.P.K., J.L.L., M.Z.M.); Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA (K.C.N.); Department of Medicine, Duke University, Durham, NC (L.E.B.); Department of Public Health Sciences and Division of Nephrology, Department of Medicine, University of Virginia, Charlottesville (J.Z.M.); and Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange (E.S., K.K.-Z.)
| | - Jennie Z Ma
- From Nephrology Section, Memphis VA Medical Center, TN (C.P.K.); Division of Nephrology, University of Tennessee Health Science Center, Memphis (C.P.K., J.L.L., M.Z.M.); Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA (K.C.N.); Department of Medicine, Duke University, Durham, NC (L.E.B.); Department of Public Health Sciences and Division of Nephrology, Department of Medicine, University of Virginia, Charlottesville (J.Z.M.); and Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange (E.S., K.K.-Z.)
| | - Elani Streja
- From Nephrology Section, Memphis VA Medical Center, TN (C.P.K.); Division of Nephrology, University of Tennessee Health Science Center, Memphis (C.P.K., J.L.L., M.Z.M.); Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA (K.C.N.); Department of Medicine, Duke University, Durham, NC (L.E.B.); Department of Public Health Sciences and Division of Nephrology, Department of Medicine, University of Virginia, Charlottesville (J.Z.M.); and Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange (E.S., K.K.-Z.)
| | - Miklos Z Molnar
- From Nephrology Section, Memphis VA Medical Center, TN (C.P.K.); Division of Nephrology, University of Tennessee Health Science Center, Memphis (C.P.K., J.L.L., M.Z.M.); Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA (K.C.N.); Department of Medicine, Duke University, Durham, NC (L.E.B.); Department of Public Health Sciences and Division of Nephrology, Department of Medicine, University of Virginia, Charlottesville (J.Z.M.); and Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange (E.S., K.K.-Z.)
| | - Kamyar Kalantar-Zadeh
- From Nephrology Section, Memphis VA Medical Center, TN (C.P.K.); Division of Nephrology, University of Tennessee Health Science Center, Memphis (C.P.K., J.L.L., M.Z.M.); Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA (K.C.N.); Department of Medicine, Duke University, Durham, NC (L.E.B.); Department of Public Health Sciences and Division of Nephrology, Department of Medicine, University of Virginia, Charlottesville (J.Z.M.); and Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange (E.S., K.K.-Z.)
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Abstract
Chronic kidney disease (CKD) is a national public health problem. Although the prevalence of early stages of CKD is similar across different racial/ethnic and socioeconomic groups, the prevalence of end-stage renal disease is greater for minorities than their non-Hispanic white peers. Paradoxically, once on dialysis, minorities experience survival rates that exceed their non-Hispanic white peers. Advancing our understanding of the unique interplay of biological, genetic, environmental, sociocultural, and health care system level factors may prompt reorientation of our approach to health promotion and disease prevention. The potential of this new approach is to create previously unimagined gains to improve patient outcomes and reduce health inequities for patients with CKD.
Collapse
Affiliation(s)
- Susanne B Nicholas
- Department of Medicine, Division of Nephrology and Division of Endocrinology, Diabetes and Hypertension, David Geffen School of Medicine at University of California, Los Angeles, CA; Charles R. Drew University of Medicine and Science, Los Angeles, CA.
| | | | | |
Collapse
|
19
|
Lee S, Reha JL, Tzeng CWD, Massarweh NN, Chang GJ, Hetz SP, Fleming JB, Lee JE, Katz MH. Race does not impact pancreatic cancer treatment and survival in an equal access federal health care system. Ann Surg Oncol 2013; 20:4073-9. [PMID: 24002535 DOI: 10.1245/s10434-013-3130-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Black patients with pancreatic adenocarcinoma (PDAC) have been reported to undergo surgical resection less frequently and to have a shorter overall survival duration than white patients. We sought to determine whether disparities in clinical management and overall survival exist between black and white patients with PDAC treated in an equal access health care system. METHODS Using the Department of Defense (DoD) tumor registry database from 1993 to 2007, patient, tumor, and treatment factors were analyzed to compare rates of therapy and survival between black and white patients. RESULTS Of 1,008 patients with PDAC, 157 were black (15 %). Thirty-six percent of black and 37 % of white patients presented with locoregional disease (p = 0.85). Among those with locoregional cancers, the odds of black patients having received surgical resection (odds ratio [OR] 1.06, 95 % confidence interval [CI] 0.60-1.89), chemotherapy (OR 0.92, 95 % CI 0.49-1.73) and radiotherapy (OR 1.14, 95 % CI 0.61-2.10) were not different from those of whites. Among those with distant disease, the odds of having received palliative chemotherapy were also similar (OR 0.91, 95 % CI 0.55-1.51). Black and white patients with PDAC had a similar median overall survival. In a multivariate analysis, as compared to whites, black race was not associated with shorter overall survival. CONCLUSIONS We observed no disparities in either management or survival between white and black patients with PDAC treated in the DoD's equal access health care system. These data suggest that improving the access of minorities with PDAC to health care may reduce disparities in their oncologic outcomes.
Collapse
Affiliation(s)
- Sukhyung Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA,
| | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Abbott KC, Nee R, Yuan CM. Making the Crooked Way Straight: Interpreting Geography and Health Care Delivery in CKD. Clin J Am Soc Nephrol 2013; 8:518-9. [DOI: 10.2215/cjn.01830213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
21
|
Vargas RB, Norris KC. Kidney disease progression and screening cost-effectiveness among African Americans. J Am Soc Nephrol 2012; 23:1915-6. [PMID: 23160510 DOI: 10.1681/asn.2012101028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
|
22
|
Arora P, Rajagopalan S, Patel N, Nainani N, Venuto RC, Lohr JW. The MDRD equation underestimates the prevalence of CKD among blacks and overestimates the prevalence of CKD among whites compared to the CKD-EPI equation: a retrospective cohort study. BMC Nephrol 2012; 13:4. [PMID: 22264268 PMCID: PMC3398292 DOI: 10.1186/1471-2369-13-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 01/20/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Black individuals are far more likely than white individuals to develop end stage renal disease (ESRD). However, earlier stages of chronic kidney disease (CKD) have been reported to be less prevalent among blacks. This disparity remains poorly understood. The objective of this study was to evaluate whether the lower prevalence of CKD among blacks in early stages of CKD might be due in part to an inability of the MDRD equation to accurately determine early stages of CKD in both the black and white population. METHODS We conducted a retrospective cohort study of 97, 451 patients seen in primary care clinic in Veterans Integrated Service Network 2 (VISN 2) over a 7 year period to determine the prevalence of CKD using both the Modification of Diet in Renal Disease (MDRD) Study equation and the more recently developed CKD Epidemiology Collaboration (CKD-EPI) equation. Demographic data, comorbid conditions, prescription of medications, and laboratory data were recorded. Logistic regression and quantile regression models were used to compare the prevalence of estimated glomerular filtration rate (eGFR) categories between black and white individuals. RESULTS The overall prevalence of CKD was lower when the CKD-EPI equation was used. Prevalence of CKD in whites was 53.2% by MDRD and 48.4% by CKD-EPI, versus 34.1% by MDRD and 34.5% by CKD-EPI in blacks. The cumulative logistic regression and quantile regression showed that when eGFR was calculated by the EPI method, blacks were as likely to present with an eGFR value less than 60 mL/min/1.73 m2 as whites. Using the CKD-EPI equation, blacks were more likely than white individuals to have stage 3b, 4 and 5 CKD. Using the MDRD method, the prevalence in blacks was only higher than in whites for stage 4 and 5 CKD. Similar results were obtained when the analysis was confined to patients over 65 years of age. CONCLUSIONS The MDRD equation overestimates the prevalence of CKD among whites and underestimates the prevalence of CKD in blacks compared to the CKD-EPI equation.
Collapse
Affiliation(s)
- Pradeep Arora
- Department of Medicine, V.A. Medical Center 3495 Bailey Ave., Buffalo, New York 14215, USA
| | | | | | | | | | | |
Collapse
|
23
|
Wetmore JB, Sankaran S, Jones PG, Reid KJ, Spertus JA. Association of decreased glomerular filtration rate with racial differences in survival after acute myocardial infarction. Clin J Am Soc Nephrol 2011; 6:733-40. [PMID: 21310822 DOI: 10.2215/cjn.02030310] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES African-American race and decreased kidney function have been associated with higher mortality after acute myocardial infarction (AMI). However, whether there are racial differences in the prevalence or prognostic importance of renal insufficiency in AMI is unknown. DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS Among 1847 AMI patients enrolled in the multicenter Prospective Registry Evaluating Myocardial Infarction Event and Recovery (PREMIER) study, estimated glomerular filtration rate (eGFR) was used to stratify prognosis and to examine potential interactions among eGFR, race, and mortality. Multivariable proportional hazards regression was used to examine the effect of race and eGFR on 3.5-year all-cause mortality. RESULTS Race and eGFR were significantly associated with mortality. After adjustment for eGFR alone, differences in mortality by race were substantially attenuated (unadjusted hazard ratio [HR] for African Americans=1.56 [95% confidence interval {CI}=1.2 to 2.1]; eGFR-adjusted HR=1.32 [95% CI=0.99 to 1.75]). A similar magnitude of attenuation in racial differences in survival was observed after adjustment for all covariates except eGFR (HR=1.29 [95% CI=0.96 to 1.72]). A final model adjusting for all covariates only slightly attenuated the association further. No interaction between race and eGFR was detected. CONCLUSIONS Renal insufficiency, which may represent chronic kidney disease, is a prognostically important comorbidity in African Americans after AMI. However, the effect of decreased eGFR on mortality is comparable between races, suggesting that preventing renal insufficiency in African Americans could be an important target to reduce racial disparities in post-AMI survival.
Collapse
Affiliation(s)
- James B Wetmore
- Division of Nephrology, Department of Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | | | | | | | | |
Collapse
|
24
|
Onumah C, Kimmel PL, Rosenberg ME. Race disparities in U.S. nephrology fellowship training. Clin J Am Soc Nephrol 2011; 6:390-4. [PMID: 21273375 DOI: 10.2215/cjn.04450510] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Renal disease disproportionately affects African-American patients. Trust has been implicated as an important factor in patient outcomes. Higher levels of trust and better interpersonal care have been reported when race of patient and physician are concordant. The purpose of this analysis was to examine trends in the racial background of U.S. medical school graduates, internal medicine residents, nephrology fellows, and patients with ESRD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data for medical school graduates were obtained from the Association of American Medical Colleges and data for internal medicine and nephrology trainees from GME Track. ESRD data were obtained from U.S. Renal Data System (USRDS) annual reports. RESULTS A significant disparity continues to exist between the proportional race makeup of African-American nephrology fellows (3.8%) and ESRD patients (32%). The low numbers of African-American nephrology fellows, and consequently new nephrologists, in light of the increase in ESRD patients has important implications for patient-centered nephrology care. CONCLUSIONS Efforts are needed to increase minority recruitment into nephrology training programs, to more closely balance the racial background of trainees and patients in hopes of fostering improved trust between ESRD caregivers and patients, increasing access to care, alleviating ESRD health care disparities, and improving patient care.
Collapse
Affiliation(s)
- Chavon Onumah
- Department of Medicine, Minneapolis VA Medical Center, University of Minnesota, One Veterans Drive, Minneapolis, MN 55417, USA
| | | | | |
Collapse
|
25
|
Wu MJ, Shu KH, Liu PH, Chiang PH, Cheng CH, Chen CH, Yu DM, Chuang YW. High risk of renal failure in stage 3B chronic kidney disease is under-recognized in standard medical screening. J Chin Med Assoc 2010; 73:515-22. [PMID: 21051028 DOI: 10.1016/s1726-4901(10)70113-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Accepted: 07/01/2010] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The objective of this study was to determine the risk of renal failure in patients with under-recognized chronic kidney disease (CKD) in the self-pay standard medical screening program of health management centers. METHODS The abbreviated Modification of Diet in Renal Disease equation was used to calculate the estimated glomerular filtration rate (eGFR) of study subjects. Study subjects with eGFR less than 60 mL/min/1.73m(2) but with normal results of routine assessment, including serum creatinine, blood urea nitrogen, urinalysis and kidney ultrasound, were defined as having under-recognized CKD. Episodes of renal failure requiring dialysis within 2 years in subjects with stage 3 to stage 5 CKD were evaluated. RESULTS A total of 15,817 subjects were recruited and 28.4% of subjects were identified by routine assessments as having a kidney problem. The prevalences of CKD 3A, 3B, 4 and 5 were 8.3%, 1.9%, 0.3% and 0.2%, respectively. All subjects with stages 4 and 5 CKD had abnormal serum creatinine levels, but 48.7% of 1,507 subjects with stage 3 CKD (stage 3A, n = 713; stage 3B, n = 21) had normal routine assessments. Subjects with under-recognized stage 3B CKD had the highest risk (20%) of developing renal failure compared to subjects with stages 3-5 CKD and abnormal results of routine assessments. CONCLUSION Identifying subjects with CKD stage 3 by the eGFR equation, especially in stage 3B, is advantageous in detecting the risk of renal failure over the routine clinical assessment that is currently carried out by health management institutions in Taiwan.
Collapse
Affiliation(s)
- Ming-Ju Wu
- Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, 160 Section 3 Chung-Kang Road, Taichung, Taiwan, R.O.C.
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Brown LJ, Clark PC, Armstrong KA, Liping Z, Dunbar SB. Identification of modifiable chronic kidney disease risk factors by gender in an African-American metabolic syndrome cohort. Nephrol Nurs J 2010; 37:133-41, 148; quiz 142. [PMID: 20462073 PMCID: PMC3088518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
African Americans experience a disproportionately greater burden of chronic kidney disease (CKD) Stage 5 than Caucasians and other minority groups. Precursors to CKD may also be components of metabolic syndrome. This study identified modifiable risk factors for CKD in an African-American metabolic syndrome cohort and compared results by gender. Both men and women (52%) had blood pressure values of 130/80 or higher, impaired fasting glucose levels of 100 to 125 mg/dL (25.5%), and body mass index greater than 25 (98.9%). There was no significant difference between genders. Appropriate clinical management of these factors may prevent or delay the onset of CKD.
Collapse
|
27
|
Morrow BD, Stewart IJ, Barnes EW, Cotant CL. Chronic kidney disease management in an academic internal medicine clinic. Clin Exp Nephrol 2009; 14:137-43. [PMID: 20024594 DOI: 10.1007/s10157-009-0247-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Accepted: 11/05/2009] [Indexed: 01/07/2023]
Abstract
OBJECTIVE We sought to evaluate the current state of chronic kidney disease (CKD) management in our academic internal medicine clinic. METHODS A retrospective review was carried out involving all patients with laboratory evidence of CKD enrolled in our clinic. We evaluated the rate of CKD recognition as well as compliance with standard guidelines. We further subdivided our results based on physician training level, presence of diabetes, recognition of CKD, age, and race. RESULTS Factors that significantly improved recognition and treatment of CKD in our study included presence of diabetes (p < 0.001), black race (p = 0.013), younger age (p = 0.004), and treatment by a resident physician (p = 0.009). Recognition of stage 3 CKD was associated with significant increases in urine protein analysis (p < 0.001) and nephrology consultation (p < 0.001). CONCLUSION Chronic kidney disease remains under-recognized and undertreated despite well-publicized guidelines and widespread use of routine eGFR reporting.
Collapse
Affiliation(s)
- Benjamin D Morrow
- Department of Medicine, Wilford Hall Medical Center, Lackland AFB, TX 78236, USA.
| | | | | | | |
Collapse
|
28
|
Derose SF, Rutkowski MP, Levin NW, Liu ILA, Shi JM, Jacobsen SJ, Crooks PW. Incidence of end-stage renal disease and death among insured African Americans with chronic kidney disease. Kidney Int 2009; 76:629-37. [DOI: 10.1038/ki.2009.209] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
29
|
Bagchi AD, Schone E, Higgins P, Granger E, Casscells SW, Croghan T. Racial and Ethnic Health Disparities in TRICARE. J Natl Med Assoc 2009; 101:663-70. [PMID: 19634587 DOI: 10.1016/s0027-9684(15)30975-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Ann D Bagchi
- Mathematica Policy Research Inc, 600 Alexander Park, Princeton, NJ 08540, USA.
| | | | | | | | | | | |
Collapse
|
30
|
Norris KC, Agodoa LY. How long can we afford to wait for equity in the renal transplant waiting list? J Am Soc Nephrol 2009; 20:1168-70. [PMID: 19470667 DOI: 10.1681/asn.2009040425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
|
31
|
Norris K, Mehrotra R, Nissenson AR. Racial differences in mortality and ESRD. Am J Kidney Dis 2008; 52:205-8. [PMID: 18640483 DOI: 10.1053/j.ajkd.2008.06.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2008] [Accepted: 06/17/2008] [Indexed: 01/13/2023]
|
32
|
Wesson DE. Is the ethnic disparity in CKD a symptom of dysfunctional primary care in the US? J Am Soc Nephrol 2008; 19:1249-51. [PMID: 18579635 DOI: 10.1681/asn.2008050478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
|
33
|
Norris K, Nissenson AR. Race, gender, and socioeconomic disparities in CKD in the United States. J Am Soc Nephrol 2008; 19:1261-70. [PMID: 18525000 DOI: 10.1681/asn.2008030276] [Citation(s) in RCA: 165] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Chronic kidney disease (CKD) is a national public health problem beset by inequities in incidence, prevalence, and complications across gender, race/ethnicity, and socioeconomic status. As health care providers, we can directly address some factors crucial for closing the disparities gap. Other factors are seemingly beyond our reach, entrenched within the fabric of our society, such as social injustice and human indifference. Paradoxically, the existence of health inequities provides unique, unrecognized opportunities for understanding biologic, environmental, sociocultural, and health care system factors that can lead to improved clinical outcomes. Several recent reports documented that structured medical care systems can reduce many CKD-related disparities and improve patient outcomes. Can the moral imperative to eliminate CKD inequities inspire the nephrology community not only to advocate for but also to demand high-quality, structured health care delivery systems for all Americans in the context of social reform that improves the ecology, health, and well-being of our communities? If so, then perhaps we can eliminate the unacceptable premature morbidity and mortality associated with CKD and the tragedy of health inequities. By so doing, we could become global leaders not only in medical technology, as we currently are, but also in health promotion and disease prevention, truly leaving no patient behind.
Collapse
Affiliation(s)
- Keith Norris
- Charles Drew University of Medicine and Science, 1731 East 120th Street, Los Angeles, CA 90059, USA.
| | | |
Collapse
|
34
|
Norris K, Nissenson A. Racial disparities in chronic kidney disease: tragedy, opportunity, or both? Clin J Am Soc Nephrol 2008; 3:314-6. [PMID: 18287256 DOI: 10.2215/cjn.00370108] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|