Addressing kidney health disparities with new national policy: the time is now

Bridging the Evidence and Practice Gap in Chronic Kidney Disease: A System Thinking Approach to Population Health

Chronic kidney disease (CKD) is common, costly, and life-limiting, requiring dialysis and transplantation in advanced stages. Although effective guideline-based therapy exists, the asymptomatic nature of CKD together with low health literacy, adverse social determinants of health, unmet behavioral health needs, and primary care providers' (PCP) limited understanding of CKD result in defects in screening and diagnosis. Care is fragmented between PCPs and specialty nephrologists, with limited time, expertise, and resources to address systemic gaps. In this article, the authors define how they classified defects in care and report the current numbers of patients exposed to these defects, both nationally and in their health system Accountable Care Organization. They describe use of the health system's three-pillar leadership model (believing, belonging, and building) to empower providers to transform CKD care. Believing entailed engaging individuals to believe defects in CKD care could be eliminated and were a collective responsibility. Belonging fostered the creation of learning communities that broke down silos and encouraged open communication and collaboration between PCPs and nephrologists. Building involved constructing a fractal management infrastructure with transparent reporting and shared accountability, which would enable success in innovation and transformation. The result is proactive and relational CKD care organized around the patient's needs in University Hospitals Systems of Excellence. Systems of excellence combine multiple domains of expertise to promote best practice guidelines and integrate care throughout the system. The authors further describe a preliminary pilot of the CKD System of Excellence in primary care.

A systematic review of psychosocial and sex-based contributors to gender disparities in the United States across the steps towards kidney transplantation

INTRODUCTION

Persistent findings suggest women and patients identified as "female" are less likely to receive a kidney transplant. Furthermore, the limited research on transplantation among transgender and gender diverse people suggests this population is susceptible to many of the same psychosocial and systemic barriers.

OBJECTIVE

This review sought to 1) highlight terminology used to elucidate gender disparities, 2) identify barriers present along the steps to transplantation, and 3) summarize contributors to gender disparities across the steps to transplantation.

METHODS

A systematic review of gender and sex disparities in the steps towards kidney transplantation was conducted in accordance with PRISMA guidelines across four social science and public health databases from 2005 to 23.

RESULTS

The search yielded 1696 initial results, 33 of which met inclusion criteria. A majority of studies followed a retrospective cohort design (n = 22, 66.7%), inconsistently used gender and sex related terminology (n = 21, 63.6%), and reported significant findings for gender and sex disparities within the steps towards transplantation (n = 28, 84.8%). Gender disparities among the earlier steps were characterized by patient-provider communication and perception of medical suitability whereas disparities in the later steps were characterized by differential outcomes based on older age, an above average BMI, and Black racial identity. Findings for transgender patients pointed to issues computing eGFR and the need for culturally tailored care.

DISCUSSION

Providers should be encouraged to critically examine the diagnostic criteria used to determine transplant eligibility and adopt practices that can be culturally tailored to meet the needs of patients.

Disparities in healthcare access experienced by Hispanic chronic kidney disease patients: a cross-sectional analysis

BACKGROUND

Chronic kidney disease (CKD) is a public health concern, and the disease disproportionately affects Hispanics. Improved healthcare access for Hispanic CKD patients can reduce the disease burden. This study assesses the healthcare access disparities experienced by Hispanic CKD patients compared to Whites.

METHODS

We analyzed three National Health and Nutrition Examination Survey (NHANES) datasets for 2013-2014, 2015-2016, and 2017-2018. The primary predictor variable was race, and the outcome variable was three domains of healthcare access: insurance status, having any routine place for healthcare, and having any health visits in the past year. Chi-square tests and unadjusted and adjusted multivariate logistic regressions were conducted. The models were adjusted for age, education, income, and CKD stages and were weighted to account for the sampling strategy.

RESULTS

The sample size was 1864 CKD patients from three two-year cycles of NHANES datasets (2013-2014, 2015-2016, and 2017-2018). The final adjusted model found that Hispanic CKD patients were more likely to be uninsured (OR: 2.52, CI 1.66-3.83) and have no routine place for healthcare (OR: 1.68, CI 1.03-2.75) than White CKD patients, but did not have differences in healthcare visits in the past year.

CONCLUSIONS

Hispanic CKD patients have limited healthcare access compared to White populations showing existing care access disparities experienced by them. Improved programs and policies are required to enhance kidney health among Hispanics and promote equity in CKD.

Sociodemographic Disparities in Adults with Kidney Failure: A Meta-Analysis

This meta-analysis aims to assess current evidence regarding sociodemographic disparities among adults with kidney failure. Medline, Scopus, Web of Science, CENTRAL, and Google Scholar were systematically searched from inception to 20 February 2022. Overall, 165 cohort studies were included. Compared to White patients, dialysis survival was significantly better among Black (hazard ratio-HR: 0.68; 95% CI: 0.61-0.75), Asian (HR: 0.67; 95% CI: 0.61-0.72) and Hispanic patients (HR: 0.80; 95% CI: 0.73-0.88). Black individuals were associated with lower rates of successful arteriovenous fistula use, peritoneal dialysis and kidney transplantation, as well as with worse graft survival. Overall survival was significantly better in females after kidney transplantation compared to males (HR: 0.87; 95% CI: 0.84-0.90). Female sex was linked to higher rates of central venous catheter use and a lower probability of kidney transplantation. Indices of low SES were associated with higher mortality risk (HR: 1.22, 95% CI: 1.14-1.31), reduced rates of dialysis with an arteriovenous fistula, peritoneal dialysis and kidney transplantation, as well as higher graft failure risk. In conclusion, Black, Asian and Hispanic patients present better survival in dialysis, while Black, female and socially deprived patients demonstrate lower rates of successful arteriovenous fistula use and limited access to kidney transplantation. PROSPERO registration: CRD42022300839.

Multimodal approaches for inequality in kidney care: turning social determinants of health into opportunities

PURPOSE OF REVIEW

Kidney disease is associated with major health and economic burdens worldwide, disproportionately carried by people in low and middle socio-demographic index quintile countries and in underprivileged communities. Social determinants such as education, income and living and working conditions strongly influence kidney health outcomes. This review synthesised recent research into multimodal interventions to promote kidney health equity that focus on the social determinants of health.

RECENT FINDINGS

Inequity in kidney healthcare commonly arises from nationality, race, sex, food insecurity, healthcare access and environmental conditions, and affects kidney health outcomes such as chronic kidney disease progression, dialysis and transplant access, morbidity and mortality. Multimodal approaches to addressing this inequity were identified, targeted to: patients, families and caregivers (nutrition, peer support, financial status, patient education and employment); healthcare teams (workforce, healthcare clinician education); health systems (data coding, technology); communities (community engagement); and health policy (clinical guidelines, policy, environment and research).

SUMMARY

The engagement of diverse patients, families, caregivers and communities in healthcare research and implementation, as well as clinical care delivery, is vital to counteracting the deleterious effects of social determinants of kidney health.