Kidney care quality cannot explain racial disparities in CKD progression, kidney failure
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Finding that patients in underrepresented groups had similar or better kidney care than white patients, researchers contended differences in care delivery cannot explain observed racial and ethnic disparities in disease progression.
The study, published in JAMA Network Open, assessed quality of care by key performance measures based on guideline recommendations and compared care performance between Black, Hispanic and Asian patients and white patients.
Importance of guideline-recommended CKD care
“Given racial and ethnic disparities in [end-stage kidney disease] ESKD and cardiovascular disease, ensuring consistent, evidence-based care delivery is a foundation for achieving health equity,” Chi D. Chu, MD, MAS, of the division of nephrology at the University of California, San Francisco, and colleagues wrote. “Racial and ethnic minority populations shoulder a disproportionate burden of [chronic kidney disease] CKD and ESKD as well as comorbid risk factors for CKD development and progression, such as diabetes and hypertension. Faster progression of CKD with several-fold greater ESKD incidence among Black and Hispanic patients compared with white patients has been consistently documented, underscoring the importance of ensuring timely, effective preventive care for CKD among minority populations.”
Despite evidence-based recommendations put forth by societies like Kidney Disease: Improving Global Outcomes, the American Heart Association and the American Diabetes Association, several studies have identified challenges with the implementation of recommendations in clinical practice, according to Chu and colleagues.
“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 [NSAID] prescription) and care delivery outcome measures (blood pressure and diabetes control),” the researchers wrote of the study objectives.
Utilizing electronic health record data for commercially insured and Medicare Advantage patients, Chu and colleagues assessed CKD care in a total of 452,238 patients with non-dialysis dependent CKD (mean age was 74 years; 1.7% were Asian; 3.4% were Hispanic; 11% were Black; 83.8% were white).
Differences in care delivery
Although care delivery outcome measures related to diabetes control (defined as hemoglobin A1c less than 7%) and blood pressure control (defined as less than 140/90 mm Hg) were similar or higher for white patients, findings revealed performance on care delivery process measures was higher among Asian, Black and Hispanic patients. Specifically, researchers found angiotensin-converting enzyme inhibitor (ACEi) and angiotensin II receptor blocker (ARB) use was 79.8% for Asian patients, 76.7% for Black patients and 79.9% for Hispanic patients compared with 72.3% for white patients; statin use was 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 was 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 was 53.9% for Asian patients, 41% for Black patients and 52.6% for Hispanic patients compared with 30.7% for white patients.
“Given prominent racial and ethnic disparities in CKD, the higher performance among Asian, Black, and Hispanic patients on multiple care delivery measures, including ACEi or ARB and statin prescription, nephrology care, and UACR testing, was somewhat unexpected,” Chu and colleagues wrote. “ ... Nevertheless, our results suggest a substantial opportunity for improved CKD care delivery across all racial and ethnic groups, including White patients, who appear to be systematically undertreated across multiple health data sources.”
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