Challenges in the Primary Care Setting: Managing Renal Disease Health Disparities

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Challenges in the Primary Care SettingManaging
Renal Disease Health Disparities
Annual Leadership Summit on Health
Disparities Washington, DC, 26-27 April 2005

• Lawrence Agodoa, M.D.
• Director, Office of Minority Health Research
  Coordination
• National Institute of Diabetes and Digestive and
  Kidney Diseases
• National Institutes of Health
• Bethesda, Maryland

National Institute of Diabetes and Digestive and
Kidney Diseases
Department of Health and Human Services
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Health Disparities in the USBackground

• Health status affects quality of life, and,
  ultimately, life expectancy.
• The quality of life in the US, in general,
  continues to improve.
• Life expectancy for Americans significantly
  improved in the 20th century.
• The improved quality of life and longevity has
  not been uniformly enjoyed by all Americans !

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Health Disparities

• Racial and Ethnic Minorities have, in general,
  suffered disproportionately from severe diseases.
• Chronic Kidney Disease and End Stage Renal
  Disease afflict racial and ethnic minority
  communities to a greater extent than in Caucasian
  communities.

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2005 Leadership Summit on Health
DisparitiesKidney Disease Health Disparities
Panel

• Introduction Magnitude of the Health
  Disparities in Chronic Kidney Disease and End
  Stage Renal Disease L. Agodoa
• Complications and Management of Chronic Kidney
  Disease and End Stage Renal Disease K. Norris
• Treatment of Chronic Kidney Disease and End Stage
  Renal Disease C. S. Modlin

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Time Trends in ESRD in the US
USRDS 2004 ADR
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Prevalent counts adjusted rates, by primary
diagnosis
illi
illi
lla
lla
December 31 point prevalent ESRD patients. Rates
adjusted for age, gender, race.
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Incident prevalent ESRD patient counts, by
modality
Incident ESRD patients December 31 point
prevalent patients.
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Number of incident point prevalent
patientsprojected to 2010
2002 prevalent count 431,284 (3.0)
Projected 418,600
Projected 111,300
2002 incident count 100,359 (-9.8)
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Medicare vs. non-Medicare spending
Medicare spending includes paid claims, estimated
Medicare Choice costs, estimated organ
acquisition costs. Non-Medicare spending includes
estimates of costs for EGHP patients for
non-Medicare ESRD patients, estimates of
patient obligations. See Appendix A for further
details.
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Adjusted Incidence Rates for ESRD by Race
Age and gender adjusted
USRDS 2004 ADR
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Racial Differences in Incidence of ESRD in
Children, Adjusted For Gender, 2000-2002
USRDS 2004 ADR
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Incidence Rate of ESRD by Race and Causes of
ESRD, Adjusted for Age and Gender, 1998-2001
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Challenges in Disparities in Kidney DiseaseKey
Questions

• What is the source of the growth of the ESRD
  burden?
• How likely are the at risk populations to go on
  to ESRD?
• How can we identify factors that promote racial
  disparities?
• What effective programs reduce the racial
  disparities?

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Trends in Diabetic ESRD Incidence Rates per
Million Population Adjusted for age, gender and
race
Incidence per million population
Cohort Year
USRDS 2004
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Racial differences in ESRD

• What are the differences in incidence rates for
  younger versus older patients entering with a
  diagnosis of ESRD due to diabetes?

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Trends in ESRD Incidence Rates per Million
Population Adjusted for age, gender and race
Incidence per million population
Cohort Year
USRDS 2004 ADR
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Trends in ESRD Prevalence Rates per Million
Population Adjusted for age, gender and race
Prevalence per million population
Cohort Year
USRDS 2003 ADR
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Trends in the patients with diabetes as the
primary cause of ESRD

• Incidence rates for younger whites with diabetes
  have fallen over the last 8 years
• These findings may reflect improved care such as
  better glycemic control and the use of ACE/ARBs
  that are renoprotective
• Incidence rates for blacks with diabetes have
  dramatically increased at an almost linear rate
  over the last 10 years
• These findings may reflect an increasing
  prevalence of hypertension
• Poor blood pressure control
• Increasing prevalence of obesity
• Increasing prevalence of diabetes with poor
  glycemic control

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Race and Chronic Kidney Disease Medicare
Population
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Racial differences in ESRD

• Access to care is less in the African American
  population in Medicare compared to the White
  population
• To the extent diabetes and cardiovascular care
  are associated with chronic kidney disease, the
  African American population is under served
• When access to care is taken into consideration
  ESRD incidence rate decline from 3.5-4.0 to 2.11
  times higher for African Americans vs Whites

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At Risk patients

• In order to address HP 2010 Objective 1, reduce
  the rate of new cases of end-stage renal disease
  (ESRD), one needs to define the at-risk
  population that is likely to develop ESRD. A
  special study by the USRDS to address this issue
  utilized the Medicare system.

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Prevalence of Diabetes, OverallCDC BRFSS Report
2000 and 5 Medicare population
All adults
All Medicare adult patients (from claims)
Random phone survey
BRFSS - Behavioral Risk Factor Surveillance
System Mokdad et al, JAMA 2001, 2861195-1200
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Prevalence of diabetes, by raceCDC BRFSS Report
2000 and 5 Medicare population
All adults
All Medicare adult patients
BRFSS - Behavioral Risk Factor Surveillance
System Mokdad et al, JAMA 2001, 2861195-1200
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What is the likelihood of the at-risk populations
advancing to CKD, DM and ESRD?
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Incidence of ESRD during one year follow-up by DM
and CKD5 Medicare sample, 1997-1998 cohort
N1,265,831(25,316,620)
N1,711(34,220)
1.7
19.7
80.8
Entry period
ESRD during one year follow-up
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What is the likelihood of the competing event of
death in the at-risk population?
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Percent of patients who developed ESRD or died
during one year follow-up by DM and CKD5
Medicare sample , 1996-1997 cohort (RR Death vs
ESRD)
19,335
188,596
33,586
N1,045,263
0.03
0.11
1.27
3.40
RR 11.3
RR 66.7
RR 154
RR 5.04
DM/CKD
DM/Non-CKD
NDM/CKD
NDM/Non-CKD
Status in the entry period
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Percent of patients who developed ESRD or died
during two year follow-up by DM and CKD5
Medicare sample , 1996-1997 cohort (RR Death vs
ESRD)
19,335
188,596
33,586
N1,045,263
0.07
5.85
2.25
0.31
RR 10.9
RR 47.3
RR 134
RR 4.96
DM/CKD
DM/Non-CKD
NoDM/CKD
NoDM/Non-CKD
Status in the entry period
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Chronic Kidney DiseaseKey Questions

• What is the source of the growth of the ESRD
  burden? Diabetes mellitus and hypertension are
  the major sources for the growth of the CKD and
  ESRD burden
• How likely are the at risk populations to go on
  to ESRD? Persons with diabetes and hypertension
  are more likely to develop chronic kidney disease
  and then progress to ESRD. However, the at risk
  population is more likely to die than go to ESRD.

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Chronic Kidney DiseaseKey Questions

• How can we identify factors that promote racial
  disparities? Racial and ethnic minorities are
  disproportionately afflicted with diseases that
  cause chronic kidney disease probably due to
  multiple risk factors, including poorer access to
  care, and other psycho-socio-economic disparities
• What effective programs reduce the racial
  disparities? Both public and private sectors
  need to explore with innovative ideas to reduce
  the disproportionate burden of kidney disease in
  racial and ethnic minority communities.