17 June 2010
Regardless of race, fewer people see a kidney specialist before starting dialysis if they live in predominantly black communities, reports a study appearing in an upcoming issue of the Journal of the American Society Nephrology (JASN). The results highlight the importance of understanding why patients in predominantly black areas are less likely to receive kidney-related care while their kidney function is clearly declining.
Black patients with kidney disease are disproportionately more likely to progress to kidney failure compared with other races. Also, a large proportion of black patients starting dialysis live in predominantly black residential areas. Suma Prakash, MD, FRCPC (University of Toronto, in Canada) and her colleagues investigated whether patient location has an effect on access to and quality of kidney-related care before starting dialysis, independent of individual patients’ race.
The researchers retrospectively studied 92,000 white and black adults who started dialysis in the United States between June 1, 2005 and October 5, 2006. They found that a residential area’s racial composition had a significant effect on a patient’s access to a kidney specialist before starting dialysis, regardless of the patient’s race. Specifically, as the percentage of blacks in residential areas increased, the likelihood of not receiving pre-dialysis kidney care from a specialist increased: 29.5% of patients living in zip codes with <5% black residents did not see a kidney specialist compared with 40.7% of those living in zip codes with >50% black residents. However, if a patient received care from a specialist before starting dialysis, the quality of this care was no different in predominantly black areas compared with other residential areas.
Dr. Prakash noted that the findings might be explained by several factors, such as the availability of pre-dialysis patient education or the accessibility of primary care doctors and kidney specialists. Addressing these findings might lead to improved access to kidney care in predominantly black residential areas.
In reviewing the results of Dr. Prakash’s study in an accompanying editorial, Sharon Stein Merkin, PhD (Geffen School of Medicine at UCLA) stated that the authors provide valuable new information by focusing on the racial composition of regions rather than individual-level factors. “Considering the important role of public health in implementing interventions at the community level, this focus is crucial for pinpointing the needs and characteristics of community-level interventions,” she wrote. Dr. Merkin added that the fact that the investigators did not find an association between racial composition and quality of nephrology care emphasizes the significance of focusing on access to nephrology care in high-risk areas as a way to reduce morbidity and mortality related to ESRD.
Study co-authors include Rudolph Rodriguez, MD, Ann O’Hare, MD (VA Puget Sound Healthcare System and University of Washington), Peter Austin, PhD (University of Toronto and Institute for Clinical Evaluative Services), Refik Saskin (Institute for Clinical Evaluative Sciences); Alicia Fernandez, MD (University of California, San Francisco); and Louise Moist, MD, FRCPC (University of Western Ontario, in London, Canada).
Disclosures: Dr. Prakash received a travel grant to present this work at the World Congress of Nephrology in Milan, Italy, 2009. Dr. Austin is supported by a Career Investigator Award from the Heart and Stroke Foundation of Ontario. Dr. Fernandez is supported by a K23RR18342 award from the National Institutes of Health/National Centre for Research Resources. Dr. O’Hare is supported by a Beeson Career Development Award from the National Institute of Aging (1K23AG28980). She also receives royalties from UpToDate and an honorarium from the Japanese Society for Foot Care. Dr. Merkin, the author of the editorial, reported no financial disclosures.
The article, entitled “Racial Composition of Residential Areas Associates with Access to Pre-ESRD Nephrology Care” (doi 10.1681/ASN.2009101008) and accompanying editorial entitled, “Neighborhoods, Race and Nephrology Care” (doi 10.1681/ASN.2010050534) will appear online at http://jasn.asnjournals.org on June 17, 2010.
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Founded in 1966, the American Society of Nephrology (ASN) is the world’s largest professional society devoted to the study of kidney disease. Comprised of 11,000 physicians and scientists, ASN continues to promote expert patient care, to advance medical research, and to educate the renal community. ASN also informs policymakers about issues of importance to kidney doctors and their patients. ASN funds research, and through its world-renowned meetings and first-class publications, disseminates information and educational tools that empower physicians.
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