Assessment of racial disparities in chronic kidney disease stage 3 and 4 care in the department of defense health system

Abstract

Background and objectives: Racial disparities in provision of healthcare are widespread in the United States but have not been specifically assessed in provision of chronic kidney disease (CKD) care.

Design, setting, participants, & measurements: We conducted a retrospective cohort study of the clinical database used in a Department of Defense (DOD) medical system. Beneficiaries studied were DOD-eligible beneficiaries with CKD stage 3 (n = 7729) and 4 (n = 589) using the modified Modification of Diet in Renal Disease (MDRD)-estimated GFR formula but requiring manual correction for Black race. Compliance with selected Kidney Disease Outcomes Quality Initiative (KDOQI) CKD recommended targets (monitoring of recommended laboratory data, prescription of recommended medications, and referral to nephrology) was assessed over a 12-mo period, stratified by CKD stage. Logistic regression analysis was used to assess whether race (White, Black, or other) was independently associated with provider compliance with targets, adjusted for demographic factors and burden of comorbid conditions.

Results: Among the targets, only monitoring of LDL cholesterol was significantly less common among Blacks. For all other measures, compliance was either not significantly different or significantly higher for Black compared with White beneficiaries. However, patients categorized as "Other" race were in general less likely to achieve targets than Whites, and at stage 3 CKD significantly less likely to achieve targets for monitoring of phosphorous, hemoglobin, and vitamin D.

Conclusions: In the DOD health system, provider compliance with selected CKD stage 3 and 4 targets was not significantly lower for Black beneficiaries than for Whites, with the exception of LDL cholesterol monitoring. Patients classified as Other race were generally less likely to achieve targets than Whites, in some patients significantly so.

Figure 1.

Among stage 3 chronic kidney disease (CKD) patients, univariate analysis of percentage compliance with Kidney Disease Outcomes Quality Initiative (KDOQI)-recommended monitoring of laboratory results and recommended medication use of each race (* represents P value <0.05 for Black race compared with White race). Data shown for ferritin and iron saturation are limited to patients with hemoglobin ≤11 g/dl. ESA, erythropoiesis stimulating agent; PTH, parathyroid hormone; ACE, angiotensin-converting enzyme; ARB, angiotensin-receptor blockers; NSAID, nonsteroidal anti-inflammatory drugs

Figure 2.

Among stage 4 CKD patients, univariate analysis of percentage compliance with KDOQI recommended monitoring of laboratory results and recommended medication use of each race (* represents P value <0.05 for Black race compared with White race). For monitoring of calcium, phosphorous, albumin, and PTH, target was considered achieved if at least four tests were ordered during a 12-mo period, as per the Methods section. Other targets were set at annual intervals (for labs) or active prescription (for medications). Data shown for ferritin and iron saturation are limited to patients with hemoglobin ≤11 g/dl.