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Race, insurance status affect access to transplantation and kidney disease treatment

February 28, 2008

'Universal access' shows promise in reducing disparities in kidney disease

Universal access to health care might help to overcome racial and ethnic barriers to treatment for kidney disease, suggest two studies in the March 2008 issue of Clinical Journal of the American Society of Nephrology.

The results should be seen as "yet another wake-up call as to how we as a medical community need to lead the health agenda for the nation, including the reduction and/or elimination of health disparities," according to an editorial by Dr. Keith Norris of Charles Drew University and Dr. Allen Nissenson of the David Geffen School of Medicine at UCLA.

In one of the two new studies, Dr. Douglas Keith of McGill University, Montreal, and colleagues analyzed data on nearly 76,000 U.S. patients wait-listed for kidney transplantation between 2001 and 2004. The goal was to identify factors affecting time on dialysis before being placed on the waiting list-the less time a patient spends on dialysis, the better the results of transplantation.

During the four-year study period, there was a significant increase in the rate of "pre-emptive listing"-that is, being placed on the transplant waiting list before starting dialysis. However, the median time spent on dialysis before wait-listing was essentially unchanged.

The rate of pre-emptive listing was lower, and time spent on dialysis was longer, for minority patients and for patients on Medicare (compared to those on private insurance).

Less-educated patients and those whose kidney disease was caused by high blood pressure also had a reduced rate of pre-emptive wait-listing and a 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 to a white patient with private insurance and 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 comments. "Our study suggests that a universal system of insurance coverage would improve access for those most disadvantaged by the current insurance system." The study is limited in that it includes only patients who actually made it to the waiting list.

In the second study, Dr. Sam W. Gao of Naval Medical Center Portsmouth (Virginia) and colleagues analyzed the quality of care for more than 8,000 patients with moderate to advanced chronic kidney disease (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 results suggested that 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. The one significant difference was lower monitoring of cholesterol levels among black patients.

"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 comments. "This may be due to universal access to care provided to all DOD beneficiaries." The study is limited in its ability to show a cause-and-affect relationship, and by the fact that it included only DOD beneficiaries.

In their editorial, Drs. Norris and Nissenson call on the nephrology community to "take the opportunity as health leaders to ensure uniform health care to all citizens and move closer to eliminating the tragedy of health inequities, and the unacceptable morbidity and mortality associated with CKD." They note that the American Society of Nephrology (ASN), National Kidney Foundation (NKF), Renal Physicians Association (RPA), and American Society of Pediatric Nephrology (ASPN) are collaborating on a legislative agenda to improve care for patients with kidney disease, focusing on appropriate funding for CKD care. In conjunction with World Kidney Day on March 13, 2008, members from ASN and NKF will visit with congressional leaders on Capitol Hill to discuss the importance of improving care for patients with kidney disease through greater access, more research, and increased education.

American Society of Nephrology