Dr. Jeffrey Dlott shares lessons 1 year after the National Kidney Foundation removed race from the kidney function equation.
Since the COVID-19 pandemic first began, gaps in care across the United States have magnified exponentially. Long-standing disparities affecting different racial and ethnic subpopulations reached the forefront of public consciousness, with COVID-19 demonstrating the critical role of social determinants of health on care and outcomes.
In September 2021, the National Kidney Foundation (NKF) took an important step toward addressing disparities in the diagnosis and treatment of chronic kidney disease (CKD), which affects an estimated 37 million adults in the US and can lead to life-threatening kidney failure.[i] CKD is also a medical condition for which social constructs of race and ethnicity have long factored into patient care.[ii]
A joint task force from the NKF and the American Society of Nephrology (ASN) recommended a switch to a new equation to calculate renal function based on a patient’s estimated glomerular filtration rate (eGFR), a quantitative marker of kidney function. The equation, which Quest Diagnostics and most other major labs have adopted, eliminated a patient’s race—specifically Black or not Black—as a variable in calculating eGFR.[iii] The race-based calculation was premised on the belief that Black patients can have, on average, higher levels of creatinine in their blood due to differences in muscle mass and other supposedly race-based factors.[iv]
Now, a year later, some estimates indicate patients being considered for renal transplant will be more likely to reach the transplant threshold because of this switch—and in a shorter timeframe.[v] This extra time may be critical to patients with CKD and to ensuring equitable allocation of transplants. Compared with White patients, Black individuals with CKD are less likely to be put on a waiting list for a kidney transplant and, once on that list, often end up waiting longer than White patients for a kidney transplant,[vi] even though kidneys are the most commonly donated organ.[vii]
Black patients are also more likely to experience gaps in care. It is no wonder that studies show African American/Black individuals are almost four times as likely as White patients to develop kidney failure.[viii]
What can the medical community do differently to help promote equitable access to care for all? The NKF-ASN’s pioneering efforts to eliminate race in kidney disease provides a worthy model. To achieve this goal, NKF-ASN convened and collaborated with hundreds of stakeholders, from physicians and medical students to patient advocates, to understand a multiplicity of views. They also arrived at conclusions based on the latest scientific evidence. Also, they didn’t stop after the calculation was changed; the NKF and the ASN are still working to address disparities in leadership and research in nephrology.
If ever there was a time for healthcare providers to address disparities, it is now, given the potential downstream consequences of delayed care during the first 2 years of the pandemic, particularly in underserved communities.
Below are some strategies for engaging patients in a prevention-focused approach to CKD and other chronic conditions.
Consider a Patient’s Social Environment
The biggest determinants of health occur outside the doctor’s office. Social factors like housing, transportation, education, food security, and economic status can all impact a person’s overall health and the care they receive.
To help close gaps in care, the healthcare industry must lend its resources to providing testing services and education programs that tackle the social determinants of health affecting historically marginalized communities head-on. By removing barriers to treatment, clinicians can reach more patients and help them understand and manage their health risks, as well as provide guidance in making lifestyle modifications to limit the progression of chronic conditions.
Physicians can and should stay in touch with patients to build trust and rapport over time. Data shows maintaining this connection can help individuals re-engage and address health gaps, reducing disparities in care by accounting for the unique needs, experiences, strengths, and challenges of each person.[ix]
Meet Them Where They Are
Experiences with discrimination may impact perspectives toward the medical community among individuals who belong to certain racial and ethnic groups. Lack of trust can hobble outreach and engagement. Here, it pays to be responsive and creative, using novel approaches to appeal to different individuals.
A virtual patient engagement or coaching platform can help this effort, as studies have shown that patients who are more engaged with their providers are more proactive, meaning they may be more likely to schedule check-ups, stay up to date on their care, and have testing done on schedule, possibly leading to better health outcomes.[x]
Data show that individuals of different groups prefer to engage in different ways. A recent study by Pack Health, a virtual patient engagement platform, found that Black participants had the highest overall number of touchpoints with their virtual health advisor when compared with other groups, while White participants preferred to connect solely via telephone calls. Furthermore, members of two or more races had the greatest engagement across mediums and saw the largest improvement in their physical health scores.[xi]
These programs can significantly benefit a patient’s health. As an example, data presented by Quest Diagnostics at the at the American Diabetes Association Scientific Sessions this year showed individuals with type 2 diabetes who stayed in a virtual, employer-sponsored diabetes reversal program for at least 6 months lowered their monthly prescription spending by 18% and experienced improvements in health risk scores like fasting glucose, weight, BMI, and waist circumference.[xii]
Look Thyself in The Mirror
Providers must examine their own biases when treating patients. Research suggests that almost 50% of White medical students and residents hold false beliefs regarding biologic variances between patients of differing races,[xiii] beliefs that may influence medical decisions and contribute to racial disparities in health-related outcomes.[xiv]
While health disparities can be reversed, it requires an authentic commitment among clinicians to connect with patients to understand their perspectives and remove racial bias through practice.[xv] To serve this goal, the American Medical Association[xvi] and the American Academy of Family Practice[xvii] have developed strategies for clinicians to address possible biases, including through training, emotional expression, intergroup contact, and more.
One year ago, the NKF and ASN took the first step in closing a gap that has existed in patient care and affected kidney care for far too long. As our nation emerges from the pandemic, more work remains. Acknowledging gaps is not enough. Health systems, physicians, and affected patient populations can work together to address disparities at their root causes. Taking these steps is an important, and necessary, path forward to a healthier world for all.
For more information, please visit: Chronic Kidney Disease | Quest Diagnostics.
[ii] Health Disparities | National Kidney Foundation
[iii] NKF and ASN Release New Way to Diagnose Kidney Diseases | National Kidney Foundation
[v] Zelnick LR, Leca N, Young B, et al. Association of the Estimated Glomerular Filtration Rate With vs Without a Coefficient for Race With Time to Eligibility for Kidney Transplant. JAMA Netw Open. 2021;4(1):e2034004. doi:10.1001/jamanetworkopen.2020.34004. PMID 33443583.
[vi] Taber DJ, Gebregziabher M, Hunt KJ, Srinivas T, Chavin KD, Baliga PK, Egede LE. Twenty years of evolving trends in racial disparities for adult kidney transplant recipients. Kidney Int. 2016 Oct;90(4):878-87. doi: 10.1016/j.kint.2016.06.029. Epub 2016 Aug 20. PMID: 27555121; PMCID: PMC5026578.
[vii] Organ Donation: Pass it On | NIH News in Health
[viii] Race, Ethnicity, & Kidney Disease | NIDDK (nih.gov)
[x] Hibbard, J. H., & Greene, J. (2013). What the evidence shows about patient activation: Better health outcomes and care experiences; fewer data on costs. Health Affairs, 32(2), 207–214. https://doi.org/10.1377/hlthaff.2012.1061
[xi] A Snapshot of Pack Health Member Engagement by Race/Ethnicity
[xiii] American medicine was built on the backs of slaves. and it still affects how doctors treat patients today. The Washington Post. June 4, 2021. Accessed June 15, 2021. https://www.washingtonpost.com/news/made-by-history/wp/2018/06/04/american-medicine-was-built-on-the-backs-of-slaves-and-it-still-affects-how-doctors-treat-patients-today/
[xiv] Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113(16):4296-301. doi:10.1073/pnas.1516047113
[xv] Provider Implicit Bias: Bringing Awareness to Clinical Practice (clinicaladvisor.com)
[xvi] Health equity education center. American Medical Association. Accessed June 6, 2022. https://edhub.ama-assn.org/health-equity-ed-center
[xvii] Implicit bias. American Academy of Family Physicians. Accessed June 6, 2022. https://www.aafp.org/about/policies/all/implicit-bias.html
Rebecca Shover