The Associations between Race and Geographic Area and Quality-of-Care Indicators in Patients Approaching ESRD

Gao, Yan; Cheung, Alfred K.; Jennie, Z.; Yu, Alison J.; Greene, Tom; Oliver, M. Norman; Yu, Wei; Norris, Keith C.

doi:10.2215/cjn.07780812

Cited by 51 publications

(57 citation statements)

References 33 publications

(35 reference statements)

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“…For example, a recent national analysis of all patients with ESRD in the USRDS revealed the lower rates of initiating dialysis with an arteriovenous fistula for black and Hispanic patients than whites, but the analysis did not assess contextual factors jointly with the patient factors (35). The few studies that examined contextual factors found some particular aspects of residential areas associated with the lower likelihood of patients having received pre-ESRD care, including residential areas with larger proportions of black residents (23), counties with greater poverty (25), large metropolitan or rural counties (24), or states with more stringent Medicaid coverage (36). Another study found substantial variation in pre-ESRD care across treatment centers (15).…”

Section: Discussionmentioning

confidence: 99%

“…Although the receipt of nephrologist care is influenced by individual as well as contextual factors such as those related to residence, prior studies have mostly examined individual factors (12,(19)(20)(21), or the few studies that examined contextual factors have generally examined them separately (22)(23)(24) or were limited to certain regional areas (15,25). An important knowledge gap exists regarding broad regional (e.g., state-level) differences in the utilization of nephrologist care among patients with CKD stages 4-5.…”

Section: Introductionmentioning

confidence: 99%

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Interstate Variation in Receipt of Nephrologist Care in US Patients Approaching ESRD

Gao

Cheung

Greene

et al. 2015

Clinical Journal of the American Society of Nephrology

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Background and objectives Although multiple factors influence access to nephrologist care in patients with CKD stages 4-5, the geographic determinants within the United States are incompletely understood. In this study, we examined interstate differences in nephrologist care among patients approaching ESRD.Design, setting, participants, & measurements This national, population-based analysis included 373,986 adult patients from the US Renal Data System, who initiated maintenance dialysis between 2005 and 2009. Multilevel logistic regression was used to examine interstate variation in nephrologist care ($12 months before ESRD) for overall and four race-age subpopulations (black or white and older or younger than 65 years). ResultsThe average state-level probability of having received nephrologist care in all states combined was 28.8% (95% confidence interval, 25.2% to 32.7%) overall and was lowest (24.3%) in the younger black subpopulation. Even at these lower levels, state-level probabilities varied considerably across states in overall and subpopulations (all P,0.001). Overall, excluding the states in the upper and lower five percentiles, the remaining states had a probability of receiving care that varied from 18.5% to 41.9%. The lower probability of receiving nephrologist care for blacks than whites among younger patients noted in most states was attenuated in older patients. Geographically, all New England states and most Midwest states had higher than average probability, whereas most Middle Atlantic and Southern states had lower than average probability. After controlling for patient factors, three state-characteristic categories, including general healthcare access measured by percentage of uninsured persons and Medicaid program performance scores, preventive care measured by percentage of receiving recommended preventive care, and socioeconomic status, contributed 55%-66% of interstate variation.Conclusions Patients living in states with better health service and socioeconomic characteristics were more likely to receive predialysis nephrologist care. The reported national black-white difference in nephrologist care was primarily driven by younger black patients being the least likely to receive care.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Interstate Variation in Receipt of Nephrologist Care in US Patients Approaching ESRD

Gao

Cheung

Greene

et al. 2015

Clinical Journal of the American Society of Nephrology

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“…However, anemia in a majority of patients with nondialysis CKD (NDD-CKD) stages 3b-5a is not treated and often delayed because of late nephrology referral and ESA reimbursement limitations (9). Between 2005 and 2010, only 28% of patients with CKD in the United States received ESA before dialysis initiation (10).…”

Section: Introductionmentioning

confidence: 99%

Oral Hypoxia–Inducible Factor Prolyl Hydroxylase Inhibitor Roxadustat (FG-4592) for the Treatment of Anemia in Patients with CKD

Provenzano

Besarab

Sun³

et al. 2016

CJASN

256

243

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Background and objectives Roxadustat , an oral hypoxia-inducible factor prolyl hydroxylase inhibitor that stimulates erythropoiesis, regulates iron metabolism, and reduces hepcidin, was evaluated in this phase 2b study for safety, efficacy, optimal dose, and dose frequency in patients with nondialysis CKD.Design, setting, participants, & measurements The 145 patients with nondialysis CKD and hemoglobin #10.5 g/dl were randomized into one of six cohorts of approximately 24 patients each with varying roxadustat starting doses (tiered weight and fixed amounts) and frequencies (two and three times weekly) followed by hemoglobin maintenance with roxadustat one to three times weekly. Treatment duration was 16 or 24 weeks. Intravenous iron was prohibited. The primary end point was the proportion of patients achieving hemoglobin increase of $1.0 g/dl from baseline and hemoglobin of $11.0 g/dl by week 17 (16 weeks of treatment). Secondary analyses included mean hemoglobin change from baseline, iron utilization, and serum lipids. Safety was evaluated by frequency/ severity of adverse events.Results Of the 145 patients enrolled, 143 were evaluable for efficacy. Overall, 92% of patients achieved hemoglobin response. Higher compared with lower starting doses led to earlier achievement of hemoglobin response. Roxadustat-induced hemoglobin increases were independent of baseline C-reactive protein levels and iron repletion status. Overall, over the first 16 treatment weeks, hepcidin levels decreased by 16.9% (P=0.004), reticulocyte hemoglobin content was maintained, and hemoglobin increased by a mean (6SD) of 1.83 (60.09) g/dl (P,0.001). Overall mean total cholesterol level was reduced by a mean (6SD) of 26 (630) mg/dl (P,0.001) after 8 weeks of therapy, independent of the use of statins or other lipid-lowering agents. No drug-related serious adverse events were reported.Conclusions In patients with nondialysis CKD who were anemic, various starting dose regimens of roxadustat were well tolerated and achieved anemia correction with reduced serum hepcidin levels. After anemia correction, hemoglobin was maintained by roxadustat at various dose frequencies without intravenous iron supplementation.

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“…There are also racial and ethnic differences in the processes of care, including dialysis dose (6,7), anemia treatment (8,9), hemodialysis vascular access (10)(11)(12)(13), and pre-ESRD clinical care (12,14). Prior studies examining hospitalization in dialysis patients usually used race, among others, as an explanatory factor or control variable (15)(16)(17)(18)(19)(20)(21).…”

Section: Introductionmentioning

confidence: 99%

Race/Ethnicity, Age, and Risk of Hospital Admission and Length of Stay during the First Year of Maintenance Hemodialysis

Gao

Norris

Greene³

et al. 2014

Clinical Journal of the American Society of Nephrology

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Background and objectives Although patients undergoing maintenance hemodialysis have exceptionally high hospitalization rates, the risk factors for hospitalizations are unclear. This study sought to examine hospitalization rates among hemodialysis patients in the United States according to both race/ethnicity and age.Design, setting, participants, & measurements US Renal Data System data on 563,281 patients beginning maintenance hemodialysis between 1995 and 2009 were analyzed. Rates of hospital admission and number of hospital days for all-cause and cause-specific hospitalizations during the first year of dialysis were compared among blacks, whites, and Hispanics in the entire cohort and subgroups stratified by age.Results After multiple adjustments, compared with whites, Hispanics overall had lower rates of both all-cause hospital days (adjusted rate ratio [aRR], 0.91; 95% confidence interval [95% CI], 0.90 to 0.93; P,0.001) and hospital admissions (aRR, 0.89; 95% CI, 0.88 to 0.90; P,0.001), whereas blacks had a lower rate of all-cause admissions (aRR, 0.95; 95% CI, 0.94 to 0.96; P,0.001). The racial/ethnic differences, however, varied by age. Hispanics exhibited the lowest rates of hospital days and admissions for all age groups#70 years, but those .80 years had higher rates than their white counterparts. The adjusted black-to-white rate ratios exhibited a U-shaped pattern with age, with higher rates for blacks in the younger and older age groups. Hospitalization rates for dialysisrelated infections were markedly higher in blacks and Hispanics than whites, which were consistent in all age groups for blacks (aRRs for hospital days ranged from 1.09 to 1.36) and all ages.60 years for Hispanics (aRRs ranged from 1.20 to 1.38).Conclusions There are significant racial/ethnic differences in hospitalization rates within first year of dialysis, which are not consistent across the age groups and also differ by causes of hospitalization. Overall, blacks and Hispanics had lower rates of all-cause hospital admissions than whites. However, younger and older blacks and older Hispanics were at greatest risk.

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The Associations between Race and Geographic Area and Quality-of-Care Indicators in Patients Approaching ESRD

Cited by 51 publications

References 33 publications

Interstate Variation in Receipt of Nephrologist Care in US Patients Approaching ESRD

Interstate Variation in Receipt of Nephrologist Care in US Patients Approaching ESRD

Oral Hypoxia–Inducible Factor Prolyl Hydroxylase Inhibitor Roxadustat (FG-4592) for the Treatment of Anemia in Patients with CKD

Race/Ethnicity, Age, and Risk of Hospital Admission and Length of Stay during the First Year of Maintenance Hemodialysis

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