A number of biological, societal, and health carerelated issues contribute to disparities in the outcomes of US patients with kidney disease, according to two articles appearing in the July 2008 issue of the Journal of the American Society Nephrology (JASN). The articles indicate that immediate and substantial efforts on a number of fronts are needed to provide better health care for affected Americans. Such concerted efforts can provide patients with the personalized, effective, and predictable care they deserve.
Many studies have documented racial and ethnic disparities in health and health care. Regarding kidney disease, black and Hispanics patients in the United States are more likely than white patients to develop kidney failure requiring dialysis or transplantation. The recently published government document, Health United States 2007, reported that black patients with end-stage renal disease (USRD) make up 33% of all patients on the kidney transplant waitlist but only 13% of the general population. Also, black patients with chronic kidney disease (CKD) accelerate faster to ESRD than white patients and are significantly more likely to develop ESRD and to do so at an earlier age than white patients.
Another government-generated document, the 2007 National Health Care Disparities Report, noted that black adults in need of chronic hemodialysis are almost equally as likely as whites to receive adequate dialysis; however, the proportion of black dialysis patients who are registered on the waitlist for transplantation remains significantly lower than that of whites.
To further examine the issues relating to health differences among patients with kidney disease, Dr. Keith Norris of Charles R. Drew University in Lynwood, CA, and Dr. Allen Nissenson of the University of California, Los Angeles, investigated the situation and provided potential solutions. The authors point to a number of factors that may play a role in these and other disparities. Patient and societal factors include: lack of trust by patients, cultural and communication barriers, and residential segregation that clusters minorities in communities with lower quality health care resources. Factors at the level of health care systems include: lower rates of insurance among minorities and under-representation of minorities in clinical trials.
Dr. Norris and Dr. Nissenson note that health care providers can directly address some factors involved in these disparities. "As a medical profession, we too frequently believe that many health issues are beyond our impact, citing them as societal issues, not realizing that we are society," they write. They urge physicians to strive to effectively communicate with all patients, to advocate for improved health care systems, and to investigate the situation by conducting relevant medical research.
In a separate article in the same issue of JASN, Dr. Neil Powe of the Johns Hopkins Medical Institutions in Baltimore, MD, also addresses health disparities in kidney disease in the United States. He notes that research has uncovered many of the biologic, socioeconomic, psychosocial, cultural, and environmental factors, as well as access and quality of health care issues, that are responsible for differences in health along racial and ethnic lines. A number of system, patient, and provider factors create complex barriers to access and quality of health care. For example, Dr. Powe writes that racial disparities in kidney donation and transplantation can arise from genetic incompatibility, waitlist registration practices, donor kidney acceptance practices, patient interest in transplantation, attitudes and beliefs about organ donation, differences in risk factors for kidney disease progression post-transplantation, and other factors.
To address these disparities, Dr. Powe suggests a number of steps by physicians and others. "There is a professional, economic, and ethical imperative to eliminate health disparities. We have the means to find and implement solutions by holding ourselves, and others, accountable," he writes.
In particular, Dr. Powe recommends that research efforts investigate why black and Hispanic patients are more likely to progress to ESRD. Is it biological (for example, genetic), non-biological (for example, lack of optimal care or poverty), or a combination of both? Dr. Powe also urges physicians, other providers, and health care delivery organizations to work to eliminate disparities as a way to improve the quality of care for all patients. Finally, Dr. Powe says that changes are needed regarding the nation's health policy. "The kidney disease community should strongly advocate for solutions that address broader issues, such as lack of awareness of kidney disease and its prevention, inadequate health insurance, and forces leading to the concentration (if not segregation) of care of racial and ethnic minorities to certain institutions, providers, and community services," he writes.
|Contact: Shari Leventhal|
American Society of Nephrology