US Racial, Ethnic Disparities in Predialysis Care Not Improved in a Decade

By Linda Carroll

August 28, 2020

(Reuters Health) - Racial and ethnic disparities in predialysis nephrology care in the United States did not improve over the course of a decade, a new study finds.

Data from more than a million U.S. adults with end-stage renal disease (ESRD) showed that minority patients' likelihood of receiving at least 12 months of specialist care before starting dialysis held steady from 2005 to 2015, researchers reported in JAMA Network Open.

"The real message here is that we need national strategies to make a difference in addressing persistent racial and ethnic disparities in access to a nephrologist prior to kidney failure," said Tanjala Purnell, an associate director of the Johns Hopkins Center for Health Equity and the Johns Hopkins Urban Health Institute.

"We want patients to have access to a specialist when they are in the early stages so the specialist can work with the primary care doctor to think about ways to stop the progression of the disease or at least slow it down," Purnell said. "Among those who continue to progress, timely access to a nephrologist is important in terms of thinking of a referral for evaluation for a transplant and having time to cope with the impending reality."

Purnell and her colleagues drew their findings from U.S. Renal Data System, which collects, analyzes and distributes information about ESRD in the United States.

They focused on adults who initiated maintenance dialysis from 2005 through 2015. The primary outcome was the receipt of at least 12 months of predialysis nephrology care.

Among the 1,000,390 adults included in the analysis--546,132 white patients (54.6%), 278,317 Black patients (27.8%), 139,854 Hispanic patients (14.0%) and 36,087 Asian patients (3.6%)--310,743 (31.1%) received at least 12 months of predialysis nephrology care.

When the researchers compared the odds that minorities would receive predialysis nephrology care to those of whites, they found that minorities, for the most part, had slightly lost ground.

In 2005 to 2007, compared with white adults, the adjusted odds ratio for receipt of at least 12 months of predialysis nephrology care was 0.82 among Black adults, 0.67 among Hispanic adults and 0.84 among Asian adults. In 2014 to 2015, the adjusted odds ratio was 0.76 among Black adults, 0.61 among Hispanic adults, and 0.90 among Asian adults.

"We knew there was a problem 10 years ago," Purnell said. "Now we still have the problem."

The data don't explain why minority patients are doing so much worse than white patients. But for many it may come down to lack of access to care, Purnell said.

"Based on national data, Black and Hispanic patients are less likely to have private health insurance and access to a primary care physician," Purnell said. "And they may not be in the position to get annual tests. So they may not get a heads up until something bad happens."

The new study is "impressive," said Tiffany Gary-Webb, an associate professor and director of the Center for Health Equity at the University of Pittsburgh Graduate School of Public Health.

"Their results were not surprising," Webb said. "They found that Blacks and Hispanics were less likely to receive predialysis nephrology care. What's more sobering is that there was no difference over time. We would have hoped that over 10 years things might have changed."

Overcoming disparities may be more complicated than simply making sure everyone has insurance, Gary-Webb said. "Social determinants of health, such as the neighborhood the patient lives in, the level of education, employment and poverty can affect access to care."

SOURCE: JAMA Network Open, online August 27, 2020.