Health Access A Factor in Renal Care

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Minorities have a lower rate of pre-emptive transplant wait-listing and spend more time on dialysis.

Universal access to health care might help to overcome racial and ethnic barriers to treatment for kidney disease, according to two studies.

In one study, Douglas Keith, MD, of McGill University in Montreal, and colleagues analyzed data on nearly 76,000 U.S. patients waitlisted for kidney transplantation between 2001 and 2004. The goal was to identify factors affecting time on dialysis before being placed on the waiting list.

During the four-year study period, researchers observed a significant increase in the rate of “pre-emptive listing,” which allows a patient to be placed on the transplant waiting list before starting dialysis. However, the median time spent on dialysis before wait-listing was essentially unchanged.

 

Overall, the researchers found that the rate of pre-emptive listing was lower, and the time spent on dialysis was longer, for minority patients and for patients on Medicare (compared with privately insured patients).

 

In addition, the investigators found that less-educated patients and those whose kidney disease was caused by high BP also had a reduced rate of pre-emptive wait-listing and longer time on dialysis. On average, a minority patient who was on Medicare and had less than a high school education spent 20 times longer on dialysis before being wait-listed compared with a privately insured white patient who had at least a high school education.

The impact of insurance was greatly reduced after age 65. At that age, Medicare patients no longer have to go through a mandatory waiting period before being eligible for kidney transplantation. However, the disparities for racial and ethnic minorities and for less-educated patients persisted after age 65.

 

“The most important issue for timely access to the waiting list is insurance or the lack of it,” Dr. Keith said. “Our study suggests that a universal system of insurance coverage would improve access for those most disadvantaged by the current insurance system.” 

 

He noted that the study was limited in that it included only patients who actually made it to the waiting list.

 

Effect of equal access

In the second study, Sam Gao, MD, of the Naval Medical Center in Portsmouth, Va., and colleagues analyzed the quality of care for more than 8,000 patients with moderate to advanced CKD treated in the Department of Defense (DOD) medical system. Their goal was to determine whether universal access to health services in the DOD system avoids racial disparities in CKD care.

The care provided to black patients with CKD in the DOD system was very similar to that provided to white patients. In some cases, measures of kidney care were higher for black patients. Monitoring of cholesterol levels was lower among black patients, however.

 

“We were able to show that blacks and whites received similar care, unlike some other aspects of medicine in the United States where blacks receive less care than whites,” Dr. Gao said. “This may be due to universal access to care provided to all DOD beneficiaries.”

 

The findings of both studies appear in the Clinical Journal of the American Society of Nephrology (2008;3:442-449;463-470).

 

The results of these two studies should be seen as yet “another wake-up call as to how the medical community needs to lead the health agenda for the nation, including the reduction and elimination of health disparities,” according to an accompanying editorial by Keith Norris, MD, of Charles Drew University in Los Angeles, and Allen Nissenson, MD, of the David Geffen School of Medicine at the University of California at Los Angeles.

 

In their editorial, they call on the nephrology community to take the opportunity as health leaders to ensure uniform health care to all citizens. They say nephrologists need to help the United States move closer to eliminating health inequities and the unacceptable morbidity and mortality associated with CKD.

 

In an interview with Renal & Urology News, Dr. Norris observed that nephrologists should know “that the lack of universal insurance and the fragmented health care we provide is a significant contributor to end-stage renal disease. Dialysis is an extremely costly health modality and as a profession we need to be examining every possible way to reduce the number of patients who are going onto dialysis and transplantation.”

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