Neighborhood poverty and racial differences in ESRD incidence

Poverty is associated with increased risk of ESRD, but its contribution to observed racial differences in disease incidence is not well-defined. To explore the contribution of neighborhood poverty to racial disparity in ESRD incidence, we analyzed a combination of US Census and ESRD Network 6 data comprising 34,767 patients that initiated dialysis in Georgia, North Carolina, or South Carolina between January 1998 and December 2002. Census tracts were used as the geographic units of analysis, and the proportion of the census tract population living below the poverty level was our measure of neighborhood poverty. Incident ESRD rates were modeled using two-level Poisson regression, where race, age and gender were individual covariates (level 1), and census tract poverty was a neighborhood covariate (level 2). Neighborhood poverty was strongly associated with higher ESRD incidence for both blacks and whites. Increasing poverty was associated with a greater disparity in ESRD rates between blacks and whites, with the former at greater risk. This raises the possibility that blacks may suffer more from lower socioeconomic conditions than whites. The disparity persisted across all poverty levels. The reasons for increasingly higher ESRD incidence among US blacks as neighborhood poverty increases remain to be explained.     

Research opportunities for reducing racial disparities in kidney disease

Several minority populations in the United States have higher risks for end-stage renal disease than does the white population. This article addresses some areas for research aimed at reducing the disproportionate risks. Four general areas are considered: health services, risk factors and causative agents, clinical trials, and awareness campaigns.     

Update and review of racial disparities in sepsis

Abstract Background: Sepsis is an excessive systemic inflammatory response activated by invasive infection. There has been substantial epidemiologic literature addressing perceived disparities in sepsis by demographic factors such as gender and race. There also have been multiple examinations of the disparities of sepsis with regard to environmental and socioeconomic factors. This paper reviews the current epidemiologic literature evaluating the association of race with the development of sepsis and its associated outcomes. Methods: Review of pertinent English-language literature. Results: Race is a marker of poverty, preexisting conditions, increased allostatic loads, and decreased access to health systems. Racial disparities and the incidence of sepsis likely are explained by a multiplicity of environmental factors that are not captured by administrative data. Conclusion: Race is a surrogate for many intangible factors that lead to the development of sepsis and inferior outcomes.     

Combining GFR and Albuminuria to Classify CKD Improves Prediction of ESRD

Despite the high prevalence of chronic kidney disease (CKD), relatively few individuals with CKD progress to ESRD. A better understanding of the risk factors for progression could improve the classification system of CKD and strategies for screening. We analyzed data from 65,589 adults who participated in the Nord-Trøndelag Health (HUNT 2) Study (1995 to 1997) and found 124 patients who progressed to ESRD after 10.3 yr of follow-up. In multivariable survival analysis, estimated GFR (eGFR) and albuminuria were independently and strongly associated with progression to ESRD: Hazard ratios for eGFR 45 to 59, 30 to 44, and 15 to 29 ml/min per 1.73 m² were 6.7, 18.8, and 65.7, respectively (P < 0.001 for all), and for micro- and macroalbuminuria were 13.0 and 47.2 (P < 0.001 for both). Hypertension, diabetes, male gender, smoking, depression, obesity, cardiovascular disease, dyslipidemia, physical activity and education did not add predictive information. Time-dependent receiver operating characteristic analyses showed that considering both the urinary albumin/creatinine ratio and eGFR substantially improved diagnostic accuracy. Referral based on current stages 3 to 4 CKD (eGFR 15 to 59 ml/min per 1.73 m²) would include 4.7% of the general population and identify 69.4% of all individuals progressing to ESRD. Referral based on our classification system would include 1.4% of the general population without losing predictive power (i.e., it would detect 65.6% of all individuals progressing to ESRD). In conclusion, all levels of reduced eGFR should be complemented by quantification of urinary albumin to predict optimally progression to ESRD.Since the publication of the Kidney Disease Outcomes Quality Initiative (K/DOQI) clinical practice guidelines on the classification of chronic kidney disease in 2002,¹ several studies based on this classification system have shown very high prevalence estimates of chronic kidney disease (CKD) in the general population (10 to 13%).^2,3 Screening for CKD is therefore increasingly suggested^1,4; however, only a small proportion of patients with stage 3 to 4 CKD progress to ESRD.⁵ There is an ongoing discussion on whether the current CKD criteria are appropriate.^6–8 Developing a risk score to identify better the patients who are at increased risk for ESRD would be of major importance for the current efforts to establish clinical guidelines and public health plans for CKD.^4,9,10Several predictors of progression to ESRD have been identified,⁹ but their independent predictive power has not been well studied either in the general population or in high-risk subgroups. Intuitively, a low estimated GFR (eGFR) is an important risk factor for ESRD, and eGFR is the backbone of the current CKD classification. High urine albumin is a well-established major risk factor for progression.⁹ Only a few studies have examined the renal risk as a function of the combination of eGFR and albuminuria.^11–14 These studies are of restricted value, however, because of exclusion of patients with diabetes¹⁴; inclusion of men only¹²; inclusion of only patients with diabetes¹³; or absence of information on potentially important risk factors, such as smoking, obesity, dyslipidemia, and cardiovascular disease.^11,14CKD screening beyond patients with known hypertension or diabetes has been proposed,^1,4 but such screening programs have remained unsatisfactory because of their limited predictive power. We used the data of the Second Nord-Trøndelag Health Study (HUNT 2), Norway, to improve such prediction. HUNT 2 is a large population-based study with a high participation rate.¹⁵ Our aim was to examine how accurately subsequent progression to ESRD could be predicted by a combined variable of baseline eGFR and urine albumin. We also tested whether further potential renal risk factors provided additional independent prediction.     

Investigating racial disparities in bariatric surgery referrals

BackgroundPrior studies investigating racial, socioeconomic, and/or insurance disparities with regard to access to care and outcomes in bariatric surgery have been performed with varying results.ObjectivesOur aim was to determine if racial or ethnic disparities exist in referral patterns for bariatric surgery at a single center.MethodsAn institutional, retrospective chart review from January 2012 through June 2017 was performed for patients meeting referral criteria to bariatric surgery. Data collection was limited to patients referred to the bariatric surgery clinic from on-site primary care clinics.ResultsIn total, 4736 patients were eligible for bariatric surgery during the study period. Patients were 63.8% female (n = 3022), and 36.2% male (n = 1714); 53.9% white (n = 2553), 37.8% black (n = 1790), and 8.3% Hispanic (n = 393). Female patients were more likely to be referred than male patients (5.5% versus 4.1%, χ² 4.59, P = .032). On univariate comparison, Hispanic patients were less likely to be referred compared with black or white patients (2.0% versus 5.3% and 5.2%, χ² 7.88, P = .019).ConclusionHispanic patients were less likely to be referred at our institution for bariatric surgery compared with white or black patients. A barrier to referral may be explained by the disproportionate number of Hispanic patients that were designated as “self-pay” rather than private insurance or Medicaid/Medicare coverage that is required for bariatric surgery referral. This finding underscores the need for further research surrounding barriers to access to care for Hispanic patients.     

Unraveling the racial disparities associated with kidney disease

In the United States, chronic kidney disease (CKD), and in particular end-stage renal disease (ESRD), represent a growing problem. Many other countries also have an increasing number of ESRD cases. Racial/ethnic disparities have been documented globally in the prevalence, incidence, and treatment of CKD, most extensively in the United States, but also in the United Kingdom, Australia, and New Zealand, among others. In many circumstances, these disparities are of a negative nature, that is, certain racial/ethnic groups fare worse than their white counterparts with respect to the treatment or outcome of CKD. However, in a few circumstances, they are of a positive nature, such as the survival advantage seen in minorities with ESRD compared with whites. The reasons for racial disparities in the prevalence, incidence, and treatment of CKD are not fully understood, although they are explained partly by coexisting medical conditions and modifiable risk factors, such as socioeconomic, lifestyle, and cultural. It is likely, however, that the complete picture incorporates a complex interaction between these sociocultural, genetic, and environmental factors. In a global society that prides itself on a high level of sensitivity and equality, there is an ethical and moral imperative to address the continuing racial/ethnic disparities in CKD and many of the factors underlying this epidemic. We review data highlighting the racial/ethnic disparities that exist in the incidence and treatment of CKD, with particular emphasis on ESRD. A better understanding of both the negative and positive racial/ethnic disparities may yield important insights, which can inform future research strategies and improve health outcomes for all patients afflicted with CKD.     

Let's get serious about racial and ethnic disparities

Racial and ethnic disparities in health and health care have been documented for over two decades in kidney disease, in a variety of other conditions, across settings, and for different medical and surgical interventions. We now have government reports that track progress on reducing racial disparities, but the pace of progress has been disheartening. The reasons for some of these disparities are known and include biologic, socioeconomic, cultural, and environmental factors as well as system, patient, and provider factors that affect access and quality of medical services. For other disparities, they remain an enigma. Solutions have been slow incoming in large part because we have not held ourselves, and others, accountable for better results. It is time to get serious about equitable health care for all of us.     

Persistent regional and racial disparities in nondirected living kidney donation

Nondirected living donors (NDLDs) are an important and growing source of kidneys to help reduce the organ shortage. In its infancy, NDLD transplantation was clustered at a few transplant centers and rarely benefited African American (AA) recipients. However, NDLDs have increased 9.4‐fold since 2000, and now are often used to initiate kidney paired donation chains. Therefore, we hypothesized that the initial geographic clustering and racial disparities may have improved. We used Scientific Registry of Transplant Recipients data to compare NDLDs and their recipients between 2008‐2015 and 2000‐2007. We found that NDLD increased an average of 12% per year, from 20 in 2000 to 188 in 2015 (IRR: 1.12, 95% CI: 1.11‐1.13, P < .001). In 2000‐2007, 18.3% of recipients of NDLD kidneys were AA; this decreased in 2008‐2015 to 15.7%. NDLD transplants initially became more evenly distributed across centers (Gini 0.91 in 2000 to Gini 0.69 in 2011), but then became more clustered at fewer transplant centers (Gini 0.75 in 2015). Despite the increased number of NDLDs, racial disparities have worsened and the center‐level distribution of NDLD transplants has narrowed in recent years.     

Lifetime risk of ESRD

Lifetime risk is the cumulative risk of experiencing an outcome between a disease-free index age and death. The lifetime risk of ESRD for a middle-aged individual is a relevant and easy to communicate measure of disease burden. We estimated lifetime risk of ESRD in a cohort of 2,895,521 adults without ESRD from 1997 to 2008. To estimate lifetime risk of ESRD by level of baseline kidney function, we analyzed a cohort of participants who had a serum creatinine measurement. We also estimated the sex- and index age-specific lifetime risk of incident ESRD and accounted for the competing risk of death. Among those individuals without ESRD at age 40 years, the lifetime risk of ESRD was 2.66% for men and 1.76% for women. The risk was higher in persons with reduced kidney function: for eGFR=44-59 ml/min per 1.73 m(2), the lifetime risk of ESRD was 7.51% for men and 3.21% for women, whereas men and women with relatively preserved kidney function (eGFR=60-89 ml/min per 1.73 m(2)) had lifetime risks of ESRD of 1.01% and 0.63%, respectively. The lifetime risk of ESRD was consistently higher for men at all ages and eGFR strata compared with women. In conclusion, approximately 1 in 40 men and 1 in 60 women of middle age will develop ESRD during their lifetimes (living into their 90s). These population-based estimates may assist individuals who make decisions regarding public health policy.     

Ethnic and racial disparities in diagnosis, treatment, and follow-up care

Studies from four areas of musculoskeletal health care disparities were reviewed to determine the root causes of the disparities and gain insight into measurable interventions. The areas of musculoskeletal health were total joint arthroplasty, amputation for patients with diabetes, rehabilitation of and impairment in patients with stroke, and morbidity associated with unintentional injuries. The Jenkins Model on Health Disparities was used to investigate and rank the contributing causes (socioeconomic status, sociocultural beliefs, racism, biology) of the health care disparities. No single root cause was found for any of the conditions. Thus, all contributing factors must be considered when planning meaningful interventions.     

Explaining insurance-related and racial disparities in the surgical management of patients with acute appendicitis

BACKGROUND: Race and insurance status influence the likelihood of undergoing laparoscopic appendectomy (LA) versus open appendectomy for the treatment of acute appendicitis. We hypothesized that these disparities are caused by presenting hospitals' use of LA. METHODS: The analysis included 26,104 appendectomies for acute appendicitis in New York State during 2003 and 2004. Multiple logistic regression was used to determine independent predictors for undergoing LA versus open appendectomy. RESULTS: Before adjustment for individual hospital use of LA, both white patients (odds ratio [OR] = 1.28, 95% confidence interval [CI] 1.21-1.36; P < .0001] and privately insured patients (OR = 1.52, 95% CI 1.44-1.61; P < .0001) were more likely to undergo LA. Controlling for differential hospitals' use of LA decreased the OR for laparoscopic surgery to 1.08 (95% CI 1.01-1.15; P = .04) for white patients and to 1.22 (95% CI 1.15-1.31; P < .0001) for privately insured patients. CONCLUSIONS: Differences in presenting hospitals' use of LA maintain racial and, to a lesser extent, insurance-related disparities in the surgical management of patients with acute appendicitis.