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Senior Associate Dean for Postgraduate Education
Division of Nephrology
Brigham and Women's Hospital and Harvard Medical School
Brigham and Women's Hospital
Ajay Singh, MBBS, FRCP, MBA: consultant/advisor/speaker: Bayer, GlaxoSmithKline, Nephrology Times, Zydus; owner: Wianno Clinical Solutions.
Anemia of chronic kidney disease (CKD) is a significant public health challenge in the United States. More than 1 in 7 US adults, or 37 million people, are estimated to have CKD, and anemia of CKD affects 4.8 million people. Anemia of CKD is associated with a reduced quality of life and higher rates of cardiovascular morbidities, hospitalizations, and mortality. Unfortunately, racial and ethnic minority patients are affected by anemia of CKD at a higher rate and are less likely to receive medical care. Here I offer some strategies for overcoming barriers to care for patients with anemia of CKD.
Greater Proportion of Black Patients With Anemia of CKD
To set the stage, I would like to discuss some data that I and my colleagues generated last year. We used the NHANES data set—a representative data set that is very commonly used in examining questions related to the population as a whole in the United States—to determine the proportion of non-Hispanic Black patients vs White patients with anemia from 1999 through 2017. Through these data, we were able to show not only that anemia is much more common in non‑Hispanic Black patients than in non‑Hispanic White patients, but also that this difference has increased over time. Indeed, in 1999 the percentage of non‑Hispanic Black patients who had anemia was approximately 22% vs closer to 30% in 2017. This finding supports the unfortunate notion that the rich have gotten richer and the people who are more disadvantaged have become even more disadvantaged. We were further able to show that a greater proportion of Black patients with CKD vs White patients or those from other races have anemia and that this difference persisted regardless of the severity of CKD.
Contributors to Disparities in Quality of Care and Clinical Outcomes for Patients With CKD
Data published a few years ago in the American Journal of Kidney Disease showed that there is a significant gap in the quality of healthcare and health outcomes between Black and White individuals, and various reasons were cited to account for this gap. The 3 reasons that I think are most impactful are social‑based health disparities, encompassing broader, institutional‑based discrimination biases, racial segregation, and economic and educational injustice; healthcare disparities, which refers to access and operation of health systems and the legal and regulatory climate that raises obstacles for Black patients to receive care efficiently; and discrimination, where there are both implicit and explicit biases and prejudice, stereotyping, and uncertainty within the healthcare system that also are obstacles to healthcare. These factors, when considered together, probably explain why Black individuals have a much higher rate of anemia with CKD. Indeed, access to treatment is very problematic, and these patients often are not receiving the treatment they need.
Strategies to Improve Health Disparities in Patients With Anemia of CKD
So how do we tackle these healthcare disparities? First, I think it is important to promote patient‑centered care. To do so, we must assemble a multidisciplinary care team; this will allow us to see patients earlier and more consistently. Furthermore, it is important to develop strategies for educating patients about anemia of CKD and identify community resources. As healthcare professionals, we must ask about social determinants of health and consider how this can affect patients’ treatment and outcomes. Including patients’ caregivers and community in treatment and educational efforts also is imperative, and it can help address any language barriers.
As an example of how this can be put into practice: We know that church is an important part of life for many Black Americans. Therefore, offering education on anemia of CKD at churches might be a way to access these individuals. It is important to think out of the box with respect to healthcare education and assemble a multidisciplinary care team that can help access nonconventional ways of educating patients.
Addressing Health Literacy
Many effective methods have been demonstrated to aid in improving health literacy. These include focusing on important points and avoiding medical jargon to communicate important information; using teach‑back techniques, in which patients repeat the information in their own words; and using visual medication schedules that are translated into different languages. These tools can help improve the ability of patients to access care.
Identification and Diagnosis
With respect to identification and diagnosis, it is important to leverage and implement detection protocols that target at-risk populations. It also is important to leverage health information systems that can help promote detection at every opportunity.
Treatment and Monitoring
Regarding treatment, we must keep abreast of and integrate evidence‑based guidelines. Educating patients on treatment options also is important so that they understand what to expect. Finally, we must constantly reassess the patient to determine if the treatment plan is working, akin to a Plan-Do-Study-Act cycle.
Increasing Participation Rates in Clinical Trials
It is critically important to increase the participation rates of racial and ethnic minority patients in clinical trials. Clinical decision-making is currently based on studies of research participants who are mostly White patients, which does not help us address any nuances that may be present in a racial and ethnic minority population. Some strategies to increase participation of underrepresented groups include cultural and linguistic adaptation of education and marketing materials; using patient navigators; building community partnerships; developing collaboration between community members, representatives of community-based organizations, and researchers; practicing shared decision-making on local health issues; and forming long-term partnerships for the dissemination of results.
In summary, racial and ethnic minority patients are at a higher risk for CKD, and—largely due to gaps in the quality of care—anemia of CKD is observed much more commonly in these populations. The presence of this anemia increases the risk of blood transfusions, which introduces further complexities, as adequate access to the healthcare system—a potential hurdle for racial and ethnic minority patients—is required for transfusions. Social determinants of health are important factors in anemia of CKD, and we must think of them as overlapping factors, from the individual to the micro system to the macro system to the exosystem. Strategies to improve disparities will need to be multipronged. A cookie-cutter approach or a one-size-fits-all strategy will not work for everyone.
What are your thoughts on the role of patient-centered care in reducing health disparities for racial and ethnic minority patients with anemia of CKD? Please answer the polling question and join the conversation by posting a comment in the discussion section.