Poverty and Racial Disparities in Kidney Disease: The REGARDS Study

Abstract

There are pronounced disparities among black compared to white Americans for risk of end-stage renal disease. This study examines whether similar relationships exist between poverty and racial disparities in chronic kidney disease (CKD) prevalence. Methods: We studied 22,538 participants in the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort study. We defined individual poverty as family income below USD 15,000 and a neighborhood as poor if 25% or more of the households were below the federal poverty level. Results: As the estimated glomerular filtration rate (GFR) declined from 50–59 to 10–19 ml/min/ 1.73 m², the black:white odds ratio (OR) for impaired kidney function increased from 0.74 (95% CI 0.66, 0.84) to 2.96 (95% CI 1.96, 5.57). Controlling for individual income below poverty, community poverty, demographic and comorbid characteristics attenuated the black:white prevalence to an OR of 0.65 (95% CI 0.57, 0.74) among individuals with a GFR of 59–50 ml/min/1.73 m² and an OR of 2.21 (95% CI 1.25, 3.93) among individuals with a GFR between 10 and 19 ml/min/ 1.73 m². Conclusion: Household, but not community poverty, was independently associated with CKD and attenuated but did not fully account for differences in CKD prevalence between whites and blacks.

Disparities in Electronic Health Record Patient Portal Use in Nephrology Clinics

“…These findings comport with earlier studies in non-nephrology settings (32)(33)(34)(35)(36). While the increase in portal adoption across groups in more recent years suggests progress, the continued differences in portal adoption among nephrology patients are disquieting because socioeconomic and racial disparities in CKD outcomes are well documented (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11). Disparities in the use of patient portals and emerging e-health technologies may reinforce or widen extant disparities.…”

“…Covariates for adjustment were chosen according to clinical significance and possible effect on portal adoption (1,(3)(4)(5)(6)(7)(8)10,11,(13)(14)(15)29,31,33,34,36,(54)(55)(56)(57)(58)(59)(60)(61)(62)(63). Sociodemographic variables were age, sex, race, marital status, insurance status, neighborhood median household income, tobacco use, and follow-up duration.…”

“…We sought to address this gap by examining portal use, including secular trends, in universityaffiliated general nephrology clinics. Given previous literature indicating that underserved groups are less likely to use EHR portals (32)(33)(34)(35)(36), we hypothesized that race, neighborhood median household income, and insurance status would be associated with portal use and of particular concern in view of documented CKD disparities in these groups (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11). In addition, we believed that BP control, a key modifiable outcome that affects CKD progression, would depend on patient adherence, self-monitoring, and patient-provider communication.…”

“…CKD contributes to substantial morbidity and mortality, particularly among vulnerable populations (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11). Patient activation (the "knowledge, skills and confidence" needed to actively engage in care) (12) is a critical feature of CKD management, wherein BP self-monitoring, dietary modification, medication adherence, nephrotoxin avoidance, and patient-provider collaboration are essential (13)(14)(15)(16).…”

Chronic Kidney Disease Identification in a High-Risk Urban Population: Does Automated eGFR Reporting Make a Difference?

“…[3][4][5] It is generally agreed that CKD recognition is necessary for optimization of CKD care, but identification of CKD may not be a priority in poor urban populations due to several factors, including the often silent nature of the disease in early stages; lack of resources to care for CKD, which often follows a protracted course; and the plethora of patient comorbid conditions that require immediate care by providers of these populations. However, it is well-established that financially disadvantaged populations are at higher risk of CKD development, progression, and mortality, [6][7][8][9][10] independent of the risks conferred by demographic and clinical factors that are common in this population. Thus, patients who receive health care in an urban safety-net system may especially benefit from increased systemwide CKD interventions to increase identification.…”