No abstract

IMPORTANCE Significant racial and ethnic disparities in chronic kidney disease (CKD) progression and outcomes are well documented, as is low use of guideline-recommended CKD care.OBJECTIVE To examine guideline-recommended CKD care delivery by race and ethnicity in a large, diverse population. DESIGN, SETTING, AND PARTICIPANTSIn this serial cross-sectional study, adult patients with CKD that did not require dialysis, defined as a persistent estimated glomerular filtration rate less than 60 mL/min/1.73 m 2 or a urine albumin-creatinine ratio of 30 mg/g or higher for at least 90 days, were identified in 2-year cross-sections from January 1, 2012, to December 31, 2019. Data from the OptumLabs Data Warehouse, a national data set of administrative and electronic health record data for commercially insured and Medicare Advantage patients, were used. EXPOSURESThe independent variables were race and ethnicity, as reported in linked electronic health records. MAIN OUTCOMES AND MEASURESOn the basis of guideline-recommended CKD care, the study examined care delivery process measures (angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker prescription for albuminuria, statin prescription, albuminuria testing, nephrology care for CKD stage 4 or higher, and avoidance of chronic nonsteroidal anti-inflammatory drug prescription) and care delivery outcome measures (blood pressure and diabetes control). RESULTSA total of 452 238 patients met the inclusion criteria (mean [SD] age, 74.0 [10.2] years; 262 089 [58.0%] female; a total of 7573 [1.7%] Asian, 49 970 [11.0%] Black, 15 540 [3.4%] Hispanic, and 379 155 [83.8%] White). Performance on process measures was higher among Asian, Black, and Hispanic patients compared with White patients for angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use (79.8% for Asian patients, 76.7% for Black patients, and 79.9% for Hispanic patients compared with 72.3% for White patients in 2018-2019), statin use (72.6% for Asian patients, 69.1% for Black patients, and 74.1% for Hispanic patients compared with 61.5% for White patients), nephrology care (64.8% for Asian patients, 72.9% for Black patients, and 69.4% for Hispanic patients compared with 58.3% for White patients), and albuminuria testing (53.9% for Asian patients, 41.0% for Black patients, and 52.6% for Hispanic patients compared with 30.7% for White patients). Achievement of blood pressure control to less than 140/90 mm Hg was similar or lower among Asian (71.8%), Black (63.3%), and Hispanic (69.8%) patients compared with White patients (72.9%). Achievement of diabetes control with hemoglobin A 1c less than 7.0% was 50.1% in Asian patients, 49.3% in Black patients, and 46.0% in Hispanic patients compared with 50.3% for White patients.

Background: Detection of chronic kidney disease (CKD) with urine albumin-to-creatinine ratio (UACR) among patients with hypertension (HTN) provides an opportunity for early treatment, potentially mitigating risk of CKD progression and cardiovascular complications. Differences in UACR testing patterns among racial/ethnic populations at risk for CKD could contribute to known disparities in CKD complications. Methods: We examined the prevalence of UACR testing among low-income adult primary care patients with HTN, defined by a new administrative code for HTN or 2 clinic blood pressures >140/90 mm Hg between January 1, 2014, and January 1, 2017, in one public health-care delivery system with a high prevalence of end-stage kidney disease among race/ethnic minorities. Logistic regression was used to identify odds of UACR testing within 1 year of a HTN diagnosis, overall, and by racial/ethnic subgroup, adjusted for demographic factors, estimated glomerular filtration rate, and HTN severity. Models were also stratified by diabetes status. Results: The cohort (n = 16,414) was racially/ethnically diverse (16% White, 21% Black, 34% Asian, 19% Hispanic, and 10% other) and 51% female. Only 35% of patients had UACR testing within 1 year of a HTN diagnosis. Among individuals without diabetes, odds of UACR testing were higher among Asians, Blacks, and Other subgroups compared to Whites (adjusted OR [aOR] 1.19; 95% CI 1.00–1.42 for Blacks; aOR 1.33; 1.13–1.56 for Asians; aOR 1.30; 1.04–1.60 for Other) but were not significantly different between Hispanics and Whites (aOR 1.17; 0.97–1.39). Among individuals with diabetes, only Asians had higher odds of UACR testing compared to Whites (aOR 1.35; 1.12–1.63). Conclusions: Prevalence of UACR testing among low-income patients with HTN is low in one public health-care delivery system, with higher odds of UACR testing among racial/ethnic minority subgroups compared to Whites without diabetes and similar odds among those with diabetes. If generalizable, less albuminuria testing may not explain higher prevalence of kidney failure in racial/ethnic minorities.

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Since 2003, US hypertension guidelines have recommended ACE (angiotensin-converting enzyme) inhibitors or ARBs (angiotensin receptor blockers) as first-line antihypertensive therapy in the presence of albuminuria (urine albumin/creatinine ratio ≥300 mg/g). To examine national trends in guideline-concordant ACE inhibitor/ARB utilization, we studied adults participating in the National Health and Nutrition Examination Surveys 2001 to 2018 with hypertension (defined by self-report of high blood pressure, systolic blood pressure ≥140 mm Hg or diastolic ≥90 mm Hg, or use of antihypertensive medications). Among 20 538 included adults, the prevalence of albuminuria ≥300 mg/g was 2.8% in 2001 to 2006, 2.8% in 2007 to 2012, and 3.2% in 2013 to 2018. Among those with albuminuria ≥300 mg/g, no consistent trends were observed for the proportion receiving ACE inhibitor/ARB treatment from 2001 to 2018 among persons with diabetes, without diabetes, or overall. In 2013 to 2018, ACE inhibitor/ARB usage in the setting of albuminuria ≥300 mg/g was 55.3% (95% CI, 46.8%–63.6%) among adults with diabetes and 33.4% (95% CI, 23.1%–45.5%) among those without diabetes. Based on US population counts, these estimates represent 1.6 million adults with albuminuria ≥300 mg/g currently not receiving ACE inhibitor/ARB therapy, nearly half of whom do not have diabetes. ACE inhibitor/ARB underutilization represents a significant gap in preventive care delivery for adults with hypertension and albuminuria that has not substantially changed over time.