Addressing kidney health disparities with new national policy: the time is now
Opportunities for new health policies to impact kidney health disparities
End-stage kidney disease (ESKD) is a debilitating condition that leads to significant patient suffering and premature mortality. In addition, ESKD care places a significant burden on the U.S. healthcare system, accounting for $50.8 billion annually in Medicare expenditures (1). With an aging society and the increased prevalence of kidney disease risk factors, such as diabetes, the ESKD incidence is expected to continue to increase leading to more lives in jeopardy at unsustainable costs under the current care delivery system (2).
Compared to White Americans, Black and Hispanic individuals have 3.4-fold and 1.3-fold ESKD prevalence, respectively, and are more likely to develop kidney failure in their lifetime (3,4). Further, communities of color have less access to pre-ESKD care to slow kidney disease progression, the option of home renal replacement therapies (5), and kidney transplantation leading to over-representation in dialysis units (6,7). Adding to morbidity in hemodialysis therapies, racial disparities exist in the optimization of dialysis vascular access (as outlined in this special issue) (8). Unfortunately, despite evidence that kidney transplantation is the optimal ESKD therapy, overall transplant outcomes are worse in Black compared to White Americans (9,10).
In 2019, the Trump administration executive order, Advancing American Kidney Health (AAKH), set the stage for bold national kidney health policy reform with three major goals (11): (I) reduce the incidence of kidney failure, (II) enhance patient choice through affordable ESKD treatments, and (III) increase access to kidney transplantation. However, the AAKH failed to address the well-recognized racial and ethnic kidney health disparities that significantly contribute to the U.S. disease burden. With the change of administration, Biden promptly announced “The Executive Order on Advancing Racial Equity and Support for Underserved Communities through the Federal Government” (12). This executive order was followed by the Health and Human Services (HHS) Equity Action Plan which is designed to promote equity by enhancing civil rights protection, business acquisitions, grant opportunities, capacity building, and prioritizing plans to reduce maternal mortality (13). Thus, in the current equity-focused policy environment, there are opportunities to incorporate policies within the AAKH framework that will positively impact kidney health equity.
Advancing awareness for screening and early identifications of kidney disease
Presently, an estimated nine in ten adults are unaware of their chronic kidney disease (CKD) status due to the asymptomatic course of the disease until late stages (14). Subsequently, 40–60% of patients initiate dialysis in an emergent, unplanned manner (15). The delay in diagnosis and patient awareness leads to risks of more rapid progression of kidney disease, subsequent comorbidities, and increased cardiovascular complications (16). Patient knowledge and health literacy along with opportunities for shared medical management are essential for positive outcomes. Further, the delay in care reduces the opportunity for shared, timely, informed decision-making on the renal replacement therapy (RRT) modality.
As outlined in AAKH, developing platforms for consumer and kidney community campaigns with a goal to enhance CKD screening are foundational. To effectively reach underserved populations, education and screening for kidney disease and pertinent risk factors must be free, pervasive, and independent from access-to-care and insurance barriers. Implementing a robust culturally-concordant community health worker program is one strategy to improve patient education (17). As non-medical, trusted individuals who share the lived experiences of target populations, community health workers have the potential to bridge the divide between the kidney health professionals and high-risk communities. Cervantes et al. outlines kidney-specific strategies to utilize community health workers including (I) CKD screening promotion, (II) social support and buddy-programs to target clinical management, (III) support to assist with RRT modality selection, and (IV) assistance to facilitate transition to ESKD (17).
The widespread use of technology and social media provide unique opportunities to promote multi-generational patient education and awareness of kidney disease. Engaging social media, ads, and marketing are creative and effective strategies used to enhance awareness within other disease entities, including breast cancer screening and prevention (18). Garnering celebrity and popular sports team endorsements, also used in other areas, may lead to broad dissemination of critical information. Overall, further research is warranted to elucidate best strategies to inform and motivate diverse communities toward health promotion. For example, exploring a shared decision framework could be useful in discussing the nuances of race-free glomerular filtration rate reporting, thereby providing a unique opportunity to boost public awareness and empowerment in communities of color.
Delaying kidney disease progression
AAKH supports embracing new therapies, developing novel biomarkers, and incorporating artificial intelligence to advance the management of kidney disease. A greater understanding of the impact of social determinants of health in kidney disease progression is needed to guide social policy. The development of the Minority Health Social Vulnerability Index by the Centers for Disease Control and Prevention, and the Office of Minority Health in 2021 may be useful in identifying communities at risk and targeting resources through local and national policy. Beyond policy intervention, scientific exploration of the interactions between social determinants of health and biological susceptibility of developing ESKD (for example, the APOL1 renal risk gene variant in people of African ancestry) is critical. These scientific observations will potentially guide pharmacogenetic/pharmacogenomic approaches to disease management toward halting progression and even cures.
Importantly, promising therapies must be affordable and accessible. Therefore, controlling medication costs are critical to providing equal access to underinsured, economically stressed populations. Current pharmacological advancements demonstrating kidney and cardiovascular benefit, like sodium-glucose cotransport-2 (SGLT2) inhibitors, have excited the kidney community (19,20), only to lead to physician and patient frustration about the cost-prohibitive barriers inherent with this new class of medication. With an estimated retail price of over $500 per month, evidence supports disparities in access to this medication class, linked to socioeconomic status, among Black and White individuals (21,22). As precision kidney medicine edges closer to reality, policies positioned to enable widespread use and benefit of innovative, life-changing therapies are a moral imperative.
Initiating value-based care models for optimal outcomes
Home dialysis therapies and kidney transplantation are cost-effective therapies associated with enhanced patient quality of life compared to in-center dialysis (23,24). AAKH supports the Center for Medicare and Medicaid Innovation (CMMI) value-based care models for kidney care. In addition, private insurers are developing similar value-based strategies for the management of chronic kidney disease with incentives and penalties. Notably, these care models, without risk adjustment parameters, are not designed to account for socioeconomic barriers (e.g., housing insecurity, transportation barriers) (25). As such, adjustments for specific populations or regions, particularly communities of color where projected outcomes are worse given social barriers, may indirectly impact outcomes and potentially exacerbate kidney health inequities through cherry-picking and lemon-dropping. Enhanced coordinated care for disadvantaged patients, home dialysis risk adjustments, and more robust documentation of social determinants of health (SDOH) are targeted strategies to address the latter limitations (25). On January 1, 2023, the inclusion of health equity incentives within Medicare payment for value-based kidney care that adjusts for low income populations is a critical step in the right direction (26). The potential to link data from the Minority Health Social Vulnerability Index to reimbursement strategies could further protect populations from unintended consequences in these new care models.
Overall, equal access is critical for these models to be universally effective and to promote optimal outcomes in CKD management, including managing comorbidities and transition to ESKD. Potentially, such actions will have the greatest impact on the highest risk patients with positive patient outcomes and substantial healthcare savings.
Incorporating telemedicine within CKD healthcare management frameworks
The implementation of telemedicine to improve care in populations that have historically faced challenges attending in-person appointments should be leveraged to enhance CKD management within the value-based care models. “Telenephrology” and home-based treatment provide greater opportunities for more flexible, integrated care that fosters patient autonomy and greater treatment access, while reducing transportation obstacles that low-income communities often face. Tan et al. noted comparable outcomes in CKD patients who received telehealth management versus those who received in-person visits, with enhanced clinical visit adherence in the telemedicine health group (27).
However, Eberly et al. discussed lessons from the COVID-19 pandemic that highlighted barriers to broadband internet, video-capable technologies, and successful implementation of telehealth in low-income and minoritized communities (28). Lew et al. outlined strategies to prevent the exacerbation of the digital divide and to promote a more harmonious integration of technology within ESKD management, including supplying self-supported, user-friendly devices in vulnerable populations, digital technology literacy courses, and the inclusion of telehealth coverage within value-based care models (29). Providing equitable access to state-of-the-art technology resources (e.g., broadband) in all communities to align with home-based innovations would have broad benefit in health care delivery from patient visits to telemonitoring and novel therapeutics.
Increasing access to kidney transplantation
Kidney transplantation is considered the optimal therapy for ESKD (24). However, currently, over 95,000 patients sit on the waitlist for a kidney (30). Historically, Black and Hispanic Americans have reduced access to transplantation due to less wait-list referrals and sparse live donation opportunities, as well as worse transplant graft survival and lower quality kidney transplants (31-35). One of the mechanisms that AAKH outlines to address kidney transplant shortages is to augment rates of living donation (11). For many Americans, the ‘cost’ of donation is challenging, but for those with economic instability, it is a significant barrier. The mean cost of donation is estimated at $36,000; however, considering potential wage losses during recovery and risks to job security, the cost may be much greater (36). Disparities in potential living donor pools among Black individuals are multifactorial with logistical issues, donor health, mistrust, and inadequate social and financial support providing some explanation. In addition, allowable cost for reimbursement may not overcome the higher poverty rates among people of color compared to White Americans due to a long history of structural racism (37). Thus, living donation should be cost-neutral for all donors and should be one of the key strategies for enhancing donation in new policies.
AAKH recognized that the federal investment in kidney disease research compared to the annual expenditure in kidney disease care is less than 2% (38). Even so, the current research portfolio, including the National Institute of Diabetes and Digestive and Kidney Diseases-supported national studies and KidneyX (kidneyx.org)—a public-private partnership to accelerate innovations like the artificial kidney—provide much hope for care advancement. Focused investments accelerate progress as seen in the significant benefits of continuous glucose monitoring, targeted cancer therapies, and the rapid development of COVID vaccines. Additional support for research on social determinants of health in kidney disease could guide further policy advancement, as well as yield important insights for effective patient dissemination and activation, artificial intelligence investigation, generalizability, and precision therapy. As national programs to boost innovation develop, like KidneyX, there should be coordinated policies to ensure advancements are equitably accessible.
Promoting workforce diversity
There have been no policies to address the lack of diversity in the healthcare workforce. A workforce that reflects the populations served has the potential to improve access, care delivery and quality, boost innovation, and advocate for policy advancement (39,40). Black and Hispanic individuals remain woefully under-represented among health professionals and the pipeline. While female physicians have made significant strides in representation in medicine, Black and Hispanic American medical student percentages remain stagnant over four decades at 5–6% of the student population (41). Further, Black physicians at the rank of Professor comprise less than 4%, thereby limiting the opportunities for academic leadership (42). A diverse pipeline is a fundamental step to building an inclusive physician workforce focused on kidney health that could have a positive impact on patients served (43). This is achieved by dismantling the social, economic, and geographic barriers that preclude the opportunities and advancement of minority and disadvantaged students within the field of medicine. Therefore, the support of national programs linked to AAKH and the HHS Equity Plan to enhance inclusiveness of health professional training and exposure to the fields of nephrology, vascular medicine, interventional radiology, transplant surgery, nephrology nursing, advanced practitioners, technicians, and related fields could have widespread benefit for patient care and address current health professional shortages.
In summary, the succession of executive orders across two administrations provide goals and strategies for transformative policy development to significantly impact kidney health equity in America. Kidney health disparities are prevalent, multifactorial, complex, and individually and economically burdensome. Therefore, on-going national cross-cutting responsive policies are required to make meaningful change resulting in happier, healthier lives for Americans with and at risk for kidney disease.
Provenance and Peer Review: This article was commissioned by the Guest Editors (Lee Kirksey, Sasan Partovi) for the series “Endovascular and Surgical Interventions in the End Stage Renal Disease Population” published in Cardiovascular Diagnosis and Therapy. The article has undergone external peer review.
Peer Review File: Available at https://cdt.amegroups.com/article/view/10.21037/cdt-22-566/prf
Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://cdt.amegroups.com/article/view/10.21037/cdt-22-566/coif). The series “Endovascular and Surgical Interventions in the End Stage Renal Disease Population” was commissioned by the editorial office without any funding or sponsorship. CAG is a council member of the American Society of Nephrology, speaker to COVID-19 for NIDDK and receives funding support from the National Institutes of Health and NIDDK. The authors have no other conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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