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Race, insurance status affect access to
Transplantation and Kidney Disease Treatment
Newswise — 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.
The ASN is a not-for-profit organization of 10,500 physicians
and scientists dedicated to the study of
nephrology and committed to providing a
forum for the promulgation of information
regarding the latest research and clinical
findings on kidney diseases.
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