Can clinical guidelines fix racial health disparities?

Racial disparities in the incidence and outcomes of chronic kidney disease is a significant public health problem. Black adults are 3.4 times more likely to develop end-stage renal disease compared to white adults, and have a higher risk of death at a younger age from kidney disease. During the first wave of the Covid-19 pandemic, researchers found that 72% of all excess deaths among American adults with kidney failure occurred among Black and Hispanic patients.

Focus on the medical isn’t moving the needle

There are a myriad of structural, medical, and social reasons behind these disparities. However, interventions to reduce disparities have largely focused on the medical. As J. Kevin Tucker, Chief of Renal Medicine at Brigham/Faulkner Hospital, writes in the Harvard Health Blog:

The explanations for the higher rates of kidney disease in African Americans have generally fallen into two broad categories: higher rates of diseases such as diabetes and hypertension that lead to kidney disease; and poorer access to insurance and medical care, leading to delayed diagnosis and faster progression of kidney disease. Therefore, efforts to reduce the rates of kidney disease in African Americans typically focused on diagnosing and treating diabetes and hypertension.

A recent study in JAMA Network Open provides an example of how treating hypertension and diabetes can only go so far in reducing disparities in kidney disease. In the article, researchers analyzed rates of adherence to clinical guidelines for kidney disease across patients of different racial and ethnic groups, to find out whether all patients were receiving evidence-based care. The guidelines they tracked included treatment with blood pressure medication, cholesterol-lowering medication, access to nephrology (kidney specialty) care, and kidney function testing.

The study authors found that Black, Hispanic, and Asian patients all received guideline-recommended care at a higher rate than white patients. Yet, their outcomes of kidney disease progression and kidney failure were still worse than white patients. These findings suggest that “improving care delivery processes alone may be inadequate for reducing disparities in CKD progression and kidney failure,” the authors write.

The need to address racism and social conditions

The progress that the medical community has made toward improving guideline-driven care for kidney disease is encouraging– but the study shows that addressing disparities through guidelines can only go so far.

“The genetics and biology of kidney disease in African Americans play a relatively minor role in their excess risk. Social determinants of health, race, and racism are equally — if not more — important in explaining the excess risk of kidney disease in African Americans relative to white Americans.”

J. Kevin Tucker, Chief of Renal Medicine at Brigham/Faulkner Hospital, Harvard Health Blog

Just as health professionals have improved guideline-driven care for kidney disease risk factors, the same effort must be put into ensuring that people of color with chronic kidney disease are given the same treatment options as white individuals. Research shows that Black patients are less likely to receive a kidney transplant, even when compared to white patients with the same chronic conditions. They are also more likely than white patients to be restricted in their dialysis provider choices because of cost, and more likely to report that they their care team failed to provide sufficient education on the treatment options, such as at-home dialysis. Research also suggests that Black patients are encouraged to use in-center dialysis rather than at-home options, which puts a larger burden on them in terms of time and transportation needs.

We also need to go further in addressing the social and structural factors that lead to kidney disease, which have their roots in structural racism as well. Food deserts and food swamps, lack of access to health care, toxic stress, and other social factors drive income and racial disparities in hypertension and diabetes. “In order to move the needle on disparities in kidney disease outcomes, it is not enough solely to understand the genetics and the biology of the condition. The societal and institutional barriers that have been erected to benefit one group of individuals over another must be torn down,” writes Tucker.