Implementing a New Kidney Function Equation Without Race Adjustment Did Not Modify Nephrology Referrals and Visits Within a Healthcare System

Core Concepts

Implementing a new eGFR equation without race adjustment did not change rates of nephrology referrals and visits within a single healthcare system, despite lowering eGFR estimates for patients documented as Black or African American.

Abstract

This study evaluated the impact of implementing a new eGFR equation (CKD-EPI 2021) without race adjustment on nephrology referrals and visits within a single healthcare system, Stanford Health Care (SHC).
Key highlights:

Prior to the eGFR equation change on December 1, 2021, most eGFR measurements at SHC relied on the CKD-EPI 2009 equation, which included race adjustment. After the change, most measurements used the CKD-EPI 2021 equation without race adjustment.
Implementing CKD-EPI 2021 lowered eGFR estimates by 10% on average for patients documented as Black or African American, and 18% of their measurements were assigned to more severe chronic kidney disease (CKD) stages. For patients not documented as Black or African American, eGFR increased by 5% on average and 12% were assigned to less severe CKD stages.
Despite these changes in eGFR values and CKD stage assignments, the implementation of CKD-EPI 2021 did not modify quarterly rates of nephrology referrals or visits for patients documented as Black or African American or the overall patient population.
Estimated quarterly rates of nephrology referrals and visits were similar with and without the implementation of CKD-EPI 2021, after adjusting for capacity at SHC nephrology clinics.
The authors conclude that changes to the eGFR equation alone are insufficient to achieve health equity in CKD care, as many other structural inequities remain.

Stats

"Implementing CKD-EPI 2021 lowered eGFR estimates by 10% on average for patients documented as Black or African American."
"18% of eGFR measurements for patients documented as Black or African American were assigned to more severe CKD stages with CKD-EPI 2021 compared to CKD-EPI 2009."
"For patients not documented as Black or African American, eGFR increased by 5% on average and 12% were assigned to less severe CKD stages with CKD-EPI 2021 compared to CKD-EPI 2009."

Quotes

"Changes to the eGFR equation are likely insufficient to achieve health equity in CKD care decision-making as many other structural inequities remain."
"Racial disparities in CKD affecting Black or African American patients cannot be attributed to eGFR-guided nephrology referral patterns alone."

Key Insights Distilled From

Algorithmic Changes Are Not Enough: Evaluating the Removal of Race Adjustment from the eGFR Equation

by Marika M. Cu... at arxiv.org 04-22-2024

https://arxiv.org/pdf/2404.12812.pdf

Deeper Inquiries

What other factors beyond the eGFR equation, such as social determinants of health and structural racism, contribute to racial disparities in chronic kidney disease and its management?

Racial disparities in chronic kidney disease (CKD) are influenced by a complex interplay of factors beyond the eGFR equation. Social determinants of health, such as socioeconomic status, access to healthcare, education, and environmental factors, play a significant role in shaping health outcomes. Patients from marginalized racial and ethnic groups often face barriers to accessing quality healthcare, leading to delays in diagnosis, suboptimal management of CKD, and poorer health outcomes. Additionally, structural racism, including discriminatory policies and practices in healthcare, housing, education, and employment, contributes to disparities in CKD care. These systemic inequities result in higher rates of CKD progression, kidney failure, and associated complications among Black or African American and other minority populations.

How can healthcare systems address the broader structural inequities that perpetuate racial disparities in kidney disease, beyond just modifying clinical algorithms?

Addressing the broader structural inequities that perpetuate racial disparities in kidney disease requires a multifaceted approach by healthcare systems. Some strategies include:

Culturally Competent Care: Healthcare providers should receive training in cultural competence to better understand and address the unique needs of diverse patient populations.
Community Partnerships: Collaborating with community organizations and leaders to improve access to healthcare services, education, and resources in underserved areas.
Health Equity Initiatives: Implementing policies and programs that prioritize health equity, diversity, and inclusion within the healthcare system.
Data Collection and Analysis: Collecting and analyzing data on race, ethnicity, and social determinants of health to identify disparities and tailor interventions accordingly.
Policy Advocacy: Advocating for policies that address social determinants of health, combat structural racism, and promote health equity at the local, state, and national levels.

What additional data or analyses would be needed to fully understand the impact of removing race adjustment from the eGFR equation on long-term kidney disease outcomes and health equity?

To fully understand the impact of removing race adjustment from the eGFR equation on long-term kidney disease outcomes and health equity, additional data and analyses are essential:

Longitudinal Studies: Long-term studies tracking patient outcomes over an extended period to assess the effects of the eGFR equation change on CKD progression, treatment decisions, and health disparities.
Qualitative Research: Qualitative research to explore patient experiences, perspectives, and barriers to care related to CKD management, especially among marginalized populations.
Health System Data Integration: Integrating data from multiple sources, including electronic health records, social determinants of health data, and patient-reported outcomes, to provide a comprehensive view of the impact of the eGFR equation change.
Comparative Analyses: Comparative analyses between healthcare systems that have implemented the race-adjusted eGFR equation and those that have not, to evaluate differences in outcomes and disparities.
Health Economics Analysis: Health economics analysis to assess the cost-effectiveness of implementing the new eGFR equation and its implications for healthcare resource allocation and equity.