Burden, access and disparities in kidney disease: chronic kidney disease hotspots and progress one step at a time

Ortíz, Alberto

doi:10.1093/ckj/sfz026

Cited by 4 publications

(5 citation statements)

References 19 publications

(20 reference statements)

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“…The consideration of life-limiting comorbidities in allocation of resources during times of crisis may contribute to maximizing the number of lives, and/or the number of life-years saved. However, given the well-described and profoundly unequal distribution of illness between racial and ethnic groups in the US [ 37 – 41 ], the consideration of comorbid conditions such as hypertension [ 42 ], diabetes [ 43 , 44 ],, and chronic kidney disease [ 45 ], is likely to function as a proxy for allocation of resources by race and ethnicity. Similarly, individuals with disabilities have a greater incidence of comorbid health conditions [ 46 ], and have more limited life expectancies [ 47 ] than able-bodied individuals.…”

Section: Discussionmentioning

confidence: 99%

Crisis Standards of Care in the USA: A Systematic Review and Implications for Equity Amidst COVID-19

Manchanda

Sanky

Appel

2020

J. Racial and Ethnic Health Disparities

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Background Crisis Standards of Care (CSC) provide a framework for the fair allocation of scarce resources during emergencies. The novel coronavirus disease (COVID-19) has disproportionately affected Black and Latinx populations in the USA. No literature exists comparing state-level CSC. It is unknown how equitably CSC would allocate resources. Methods The authors identified all publicly available state-level CSC through online searches and communication with state governments. Publicly available CSC were systematically reviewed for content including ethical framework and prioritization strategy. Results CSC were identified for 29 states. Ethical principles were explicitly stated in 23 (79.3%). Equity was listed as a guiding ethical principle in 15 (51.7%); 19 (65.5%) said decisions should not factor in race, ethnicity, disability, and other identity-based factors. Ten states (34.4%) allowed for consideration of societal value, which could lead to prioritization of health care workers and other essential personnel. Twenty-one (72.4%) CSC provided a specific strategy for prioritizing patients for critical care resources, e.g., ventilators. All incorporated Sequential Organ Failure Assessment scores; 15 (71.4%) of these specific CSC considered comorbid conditions (e.g., cardiac disease, renal failure, malignancy) in resource allocation decisions. Conclusion There is wide variability in the existence and specificity of CSC across the USA. CSC may disproportionately impact disadvantaged populations due to inequities in comorbid condition prevalence, expected lifespan, and other effects of systemic racism.

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Section: Discussionmentioning

confidence: 99%

Crisis Standards of Care in the USA: A Systematic Review and Implications for Equity Amidst COVID-19

Manchanda

Sanky

Appel

2020

J. Racial and Ethnic Health Disparities

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“…8 The assignment of African-Americans to less severe CKD stages due to a race multiplier term in the estimated glomerular filtration rate (eGFR) equations may contribute to care delivery disparities. 9,10 For example, the United Network for Organ Sharing encourages transplantation evaluation when eGFR is 20-30 ml/min/1.73 m [2 11 while other guidelines recommend referral at ≤ 20 ml/min/ 1.73 m 2 . 12 Timely transplant referral has particular importance for African-Americans, who tend to have more rapid progression through CKD stages, and given that eGFR influences care delivery decisions, classification into less severe CKD stages could delay appropriate care.…”

Section: Introductionmentioning

confidence: 99%

Examining the Potential Impact of Race Multiplier Utilization in Estimated Glomerular Filtration Rate Calculation on African-American Care Outcomes

et al. 2020

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BACKGROUND: Advancing health equity entails reducing disparities in care. African-American patients with chronic kidney disease (CKD) have poorer outcomes, including dialysis access placement and transplantation. Estimated glomerular filtration rate (eGFR) equations, which assign higher eGFR values to African-American patients, may be a mechanism for inequitable outcomes. Electronic health record-based registries enable population-based examination of care across racial groups. OBJECTIVE: To examine the impact of the race multiplier for African-Americans in the CKD-EPI eGFR equation on CKD classification and care delivery. DESIGN: Cross-sectional study SETTING: Two large academic medical centers and affiliated community primary care and specialty practices. PARTICIPANTS: A total of 56,845 patients in the Partners HealthCare System CKD registry in June 2019, among whom 2225 (3.9%) were African-American. MEASUREMENTS: Exposures included race, age, sex, comorbidities, and eGFR. Outcomes were transplant referral and dialysis access placement. RESULTS: Of 2225 African-American patients, 743 (33.4%) would hypothetically be reclassified to a more severe CKD stage if the race multiplier were removed from the CKD-EPI equation. Similarly, 167 of 687 (24.3%) would be reclassified from stage 3B to stage 4. Finally, 64 of 2069 patients (3.1%) would be reassigned from eGFR > 20 ml/min/1.73 m 2 to eGFR ≤ 20 ml/min/ 1.73 m 2 , meeting the criterion for accumulating kidney transplant priority. Zero of 64 African-American patients with an eGFR ≤ 20 ml/min/1.73 m 2 after the race multiplier was removed were referred, evaluated, or waitlisted for kidney transplant, compared to 19.2% of African-American patients with eGFR ≤ 20 ml/min/1.73 m 2 with the default CKD-EPI equation.LIMITATIONS: Single healthcare system in the Northeastern United States and relatively small African-American patient cohort may limit generalizability. CONCLUSIONS: Our study reveals a meaningful impact of race-adjusted eGFR on the care provided to the African-American CKD patient population.

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“…Descriptive statistics were reported as mean (standard deviation) for normal distributions or median (interquartile range) for non-normal distributions. Standard error was calculated using the method described by DeLong et al, 19 and confidence intervals were calculated with the exact binomial test. For continuous variables, unpaired Student's t tests (normal distribution) or Mann-Whitney U tests (non-normal distribution) were used for two-group comparisons.…”

Section: Star+methodsmentioning

confidence: 99%

“…13 Given the poor discrimination by SOFA scores, we hypothesized that algorithms that incorporate comorbidities, in addition to SOFA scores, have superior discriminant ability compared to algorithms that use SOFA scores alone. Because comorbidities are associated with race and ethnicity, [14][15][16][17][18][19] we also hypothesized that incorporating comorbidities could alter the performance of CSC algorithms by race and ethnicity.…”

Section: Introductionmentioning

confidence: 99%

Performance of crisis standards of care guidelines in a cohort of critically ill COVID-19 patients in the United States

Jezmir¹,

Bharadwaj²,

Chaitoff³

et al. 2021

Cell Reports Medicine

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Many US states published crisis standards of care (CSC) guidelines for allocating scarce critical care resources during the COVID-19 pandemic. However, the performance of these guidelines in maximizing population benefit has not been well tested. In 2,272 adults with COVID-19 requiring ICU admission drawn from the STOP-COVID multicenter cohort, we tested three approaches to CSC algorithms: SOFA scores grouped into ranges, SOFA score ranges plus comorbidities, and a hypothetical approach using raw SOFA scores not grouped into ranges. We found that area under receiver operating characteristic (AUROC) curves for all three algorithms demonstrate only modest discrimination for 28-day mortality. Adding comorbidity scoring modestly improves algorithm performance over SOFA scores alone. The algorithm incorporating comorbidities has modestly worse predictive performance for Black compared to White patients. CSC algorithms should be empirically examined to refine approaches to the allocation of scarce resources during pandemics and to avoid potential exacerbation of racial inequities.

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Burden, access and disparities in kidney disease: chronic kidney disease hotspots and progress one step at a time

Cited by 4 publications

References 19 publications

Crisis Standards of Care in the USA: A Systematic Review and Implications for Equity Amidst COVID-19

Crisis Standards of Care in the USA: A Systematic Review and Implications for Equity Amidst COVID-19

Examining the Potential Impact of Race Multiplier Utilization in Estimated Glomerular Filtration Rate Calculation on African-American Care Outcomes

Performance of crisis standards of care guidelines in a cohort of critically ill COVID-19 patients in the United States

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