Among patients with nondialysis-dependent chronic kidney disease (CKD), racial and ethnic minorities are more likely than White individuals to receive guideline-directed care in several key areas, a new study finds. Black and Hispanic patients, however, are less likely to have their high blood pressure and diabetes under control.
Of 452,238 commercially insured and Medicare Advantage patients with CKD who received care during 2012 to 2019, 1.7% were categorized as Asian, 11.0% Black, 3.4% Hispanic, and 83.8% White.
Investigators led by Chi D. Chu, MD, MAS, of the University of California, San Francisco, identified CKD care delivery measures based on Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guidelines. Use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers was higher among Black (76.7%), Hispanic (79.9%), and Asian (79.8%) patients compared with White patients (72.3%) in 2018-2019, they reported in JAMA Network Open. Statin use was also higher among minority groups — Black (69.1%), Asian (72.6%), and Hispanic (74.1%) — compared with White patients (61.5%). Avoidance of long-term prescription of nonsteroidal anti-inflammatory drugs (NSAIDs) was consistently greater than 80% across all racial groups. The investigators had no data on use of over-the-counter NSAIDs.
Predialysis nephrology care was received by greater proportions of non-White (64.8% Asian, 69.4% Hispanic, and 72.9% Black) compared with White patients (58.3%), the investigators reported. Albuminuria testing occurred in 41.0%, 52.6%, and 53.9% of Black, Hispanic, and Asian patients, respectively, but only 30.7% of White patients. Compared with White patients, Black, Hispanic, and Asian patients with an estimated glomerular filtration rate less than 30 mL/min/1.73 m2 had significant 73%, 61%, and 32% increased odds of receiving nephrology care, respectively, in a fully adjusted model. Black, Hispanic, and Asian patients also had 14%, 63%, and 113% increased odds of albuminuria testing, respectively.
Although minority groups received guideline-recommended care in key areas, a lower proportion of Black patients (63.3%) achieved blood pressure control to less than 140/90 mm Hg, compared with Hispanic (69.8%), Asian (71.8%), and White patients (72.9%). Diabetes control to a hemoglobin A1c target of less than 7.0% occurred in 46.0% and 49.3% of Hispanic and Black patients, respectively, compared with 50.1% and 50.3% of Asian and White patients, respectively. Using White patients as the reference group, Black, Hispanic, and Asian patients had significant 30%, 16%, and 14% decreased odds of blood pressure control and 6%, 21%, and 7% decreased odds of glycemic control, respectively.
“Lower achievement of blood pressure and glycemic targets despite better performance on process-type care delivery measures suggests that more aggressive health care — testing, prescribing, and referring to match guideline recommendations — is likely inadequate in isolation for narrowing health disparities,” Dr Chu’s team concluded. “An alternative might be exploring how interventions addressing social determinants of health (eg, food insecurity, housing instability, and health literacy) may help mitigate the burden of CKD risk factors and health consequences among non-White individuals, including Black and Hispanic persons.”
Genetic risk factors for CKD progression, such as APOL1 high-risk alleles in patients with Black ancestry, may also contribute to racial disparities, they suggested.
Disclosure: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Chu CD, Powe NR, McCulloch CE, et al. Trends in chronic kidney disease care in the US by race and ethnicity, 2012-2019. JAMA Netw Open. 2021;4(9):e2127014. Published online September 27, 2021. doi:10.1001/jamanetworkopen.2021.27014