CKD Care Trends by Race, Ethnicity

Significant racial and ethnic disparities continue to exist among patients with chronic kidney disease (CKD) in the United States. To better understand the source of these disparities, the authors of a recent study examined the guideline-recommended care delivery for patients with CKD who are part of racial and ethnic minorities.

To learn more about the study findings and their implications, Consultant360 reached out to study author Chi Chu, MD, MAS, who is an assistant professor of medicine at the University of California, San Francisco.

Consultant360: What was the impetus for your study? 

Chi Chu: It has been well-documented that many patients with CKD do not receive guideline-recommended care. At the same time, racial and ethnic disparities in CKD outcomes, such as progression to kidney failure needing dialysis, are also well-described and unfortunately have been fairly consistent over time. In a large national database of patients with CKD, we wanted to comprehensively examine elements of CKD care and compare receipt of recommended CKD care by race and ethnicity. 

C360: The results of your study indicate that Asian, Black, and Hispanic patients had higher performance on CKD care measures when compared with White patients, despite higher rates of disease progression and adverse health outcomes. Is this a result that surprised you, or did you anticipate this?

CC: The finding of higher performance measures among Asian, Black, and Hispanic patients was somewhat surprising, but it turns out that similar findings had been seen in some smaller previous studies within health care systems. However, similar or worse achievement of blood pressure and diabetes control targets compared with White patients was not as surprising. These were somewhat dissonant findings and to us, suggesting that optimizing medical treatment per se is likely to be insufficient for eliminating disparities in clinical outcomes.

C360: Your study notes that prior research has highlighted significant gaps in the guideline-recommended care for patients with CKD. How can this knowledge, in combination with the results of your study, be used to improve guideline-recommended care and reduce disparities among patients with CKD? 

CC: In our results, a notable finding was not just suboptimal performance across a variety of measures, but also the remarkable stability of performance year after year for nearly a decade. The burden of CKD contributes to so much morbidity in the United States and the world. To us, this reinforces the need to understand how to deliver optimal care for people with CKD in order to reduce disease progression and complications.

Do we need better education for clinicians on prevention of kidney failure, akin to messaging and action on stroke or heart disease prevention? Do we need more effective strategies to identify CKD at the population level and potentially assist primary care clinicians with early CKD management? Do we need a greater focus on CKD at the policy level, where efforts in quality measurement and improving care have historically focused almost exclusively on dialysis, a late complication of CKD? There is still a huge opportunity for improvement, and I think the answer will be some combination of all of the above.

C360: Do any other knowledge gaps remain on socioeconomic factors, such as income level or education, that may contribute to health care disparities in patients with CKD? What are the next steps for research in this area?

CC: Socioeconomic factors, such as income level or education, are crucially important determinants of health. But the extent to which they contribute to health and health care disparities in CKD, as well as which interventions may mitigate their contributions, remains underexplored.

Studies and national surveillance data have consistently documented more rapid progression of CKD and incident kidney failure among Black and Hispanic persons, for instance, and it is difficult to attribute these sizable disparities just to differences in care such as angiotensin-converting enzyme inhibitor prescription. So, a focus on better quality of care by "traditional" metrics, guideline-recommended treatment, and so forth may not close these disparities as much as we would hope. Many disparities are rooted in economic and social factors such as structural racism, so we really need to better understand how these factors contribute to poor CKD outcomes in order to design interventions to meaningfully reduce the burden of CKD.

C360: What are the key takeaways from your research? How can health care providers implement these messages into their clinical practice?

CC: The key takeaway for health care providers is that there is significant room for improvement in implementation of guideline-recommended CKD treatment, irrespective of race and ethnicity. CKD is a highly prevalent disease, and we are fortunate that there is a growing list of therapies proven to reduce CKD progression and improve outcomes. However, the opportunity for benefit can only be realized if we can reliably detect and risk stratify CKD, especially with albuminuria testing, and if we can execute on delivering these proven therapies to patients with CKD.

Reference:

Chu CD, Powe NR, McCulloch CE, et al. Trends in chronic kidney disease care in the US by race and ethnicity, 2012-2019. JAMA Netw Open. 2021;4(9):e2127014. doi:10.1001/jamanetworkopen.2021.27014