Assessment of Racial Disparities in Chronic Kidney Disease Stage 3 and 4 Care in the Department of Defense Health System

Abstract

Background and objectives: Racial disparities in provision of healthcare are widespread in the United States but have not been specifically assessed in provision of chronic kidney disease (CKD) care.Design, setting, participants, & measurements: We conducted a retrospective cohort study of the clinical database used in a Department of Defense (DOD) medical system. Beneficiaries studied were DOD-eligible beneficiaries with CKD stage 3 (n ‫؍‬ 7729) and 4 (n ‫؍‬ 589) using the modified Modification of Diet in Renal Disease (MDRD)-estimated GFR formula but requiring manual correction for Black race. Compliance with selected Kidney Disease Outcomes Quality Initiative (KDOQI) CKD recommended targets (monitoring of recommended laboratory data, prescription of recommended medications, and referral to nephrology) was assessed over a 12-mo period, stratified by CKD stage. Logistic regression analysis was used to assess whether race (White, Black, or other) was independently associated with provider compliance with targets, adjusted for demographic factors and burden of comorbid conditions. Results: Among the targets, only monitoring of LDL cholesterol was significantly less common among Blacks. For all other measures, compliance was either not significantly different or significantly higher for Black compared with White beneficiaries. However, patients categorized as "Other" race were in general less likely to achieve targets than Whites, and at stage 3 CKD significantly less likely to achieve targets for monitoring of phosphorous, hemoglobin, and vitamin D.Conclusions: In the DOD health system, provider compliance with selected CKD stage 3 and 4 targets was not significantly lower for Black beneficiaries than for Whites, with the exception of LDL cholesterol monitoring. Patients classified as Other race were generally less likely to achieve targets than Whites, in some patients significantly so.

Kidney Disease Progression and Screening Cost-Effectiveness among African Americans

“…11 Large systems that provide a form of universal access to care for a relatively captured constituency such as Department of Defense beneficiaries have reported improved outcomes and reduced disparities for select indicators of stages 3 and 4 CKD quality care. 12 On balance, their findings support the inference that structured performance measures in a universal care type of environment, not only improve quality of care but may reduce and/or eliminate many health care disparities.…”

How Long Can We Afford to Wait for Equity in the Renal Transplant Waiting List?

“…1 More recently, nephrology has witnessed an awakening to understanding many of the underlying factors that contribute to ESRD, [2][3][4][5] as well as addressing the quality of care for patients afflicted with chronic kidney disease (CKD) or ESRD, especially across racial and ethnic, gender, and income demographics. 6,7 As Powe 2 notes in his urge for us to take disparities seriously, when it comes to kidney transplants, white patients in 2004 were 30% more likely to receive a transplant within 2 yr than black patients and 20% more likely than Hispanic patients.…”

“…In contrast, IL-2R Abs have been the subject of numerous placebo-controlled, randomized trials, which showed a reduction in rejection rates by 28 to 42% compared with placebo. [2][3][4][5] Before the trial of Noel et al 6 in this issue of JASN, at least four randomized, controlled trials compared ATG with IL-2R Abs. Three of these 7-9 used triple immunosuppression with cyclosporine, mycophenolate mofetil, and steroids and were limited to patients with low immunologic risk.…”

“…Like the study by Brennan et al, 10 the study by Noel et al 6 is a well-designed, randomized, controlled trial limited to highrisk recipients. It also compares ATG with IL-2R Ab on a background of triple immunosuppression.…”

Racial Disparities in Chronic Kidney Disease

“…Simultaneously, the recognition of racial and ethnic disparities in health outcomes may provide unique opportunities to advance our understanding of biologic mediators; environmental, psychosocial, and cultural factors; and health risk behaviors that ultimately influence clinical outcomes (3,4). In this issue of CJASN, Gao et al (5) examine select indicators of quality care for stages 3 and 4 chronic kidney disease (CKD) in a clinical database of more than 13,000 Department of Defense beneficiaries. They assessed whether race (white, black, or other) was independently associated with provider compliance with selected Kidney Disease Outcomes Quality Initiative (KDOQI) CKD recommended targets during a 12-mo period.…”