Home dialysis use varies by race, largely due to socioeconomic factors
Differences in socioeconomic factors accounted for many, but not all, of the disparities observed between white and minority patients in home dialysis use, according to study results.
“Racial and ethnic differences in home dialysis use have been known for some time, but the potential mechanisms behind them had not been well explored,” Jenny I. Shen, MD, MS, assistant professor of medicine at University of California, Los Angeles and investigator at the Los Angeles Biomedical Institute at Harbor-UCLA Medical Center, told Healio Nephrology. “Many of the socioeconomic characteristics that are more common among home dialysis patients, like having received pre-dialysis nephrology care or having private insurance, are less prevalent among minority patients.”
With the hypothesis that “adjusting for such differences in socioeconomic factors would largely attenuate the racial and ethnic disparities in home dialysis use,” researchers included 523,526 patients who initiated treatment with either in-center hemodialysis, home hemodialysis or peroneal dialysis from 2005 to 2013. Patients were categorized by race/ethnicity as non-Hispanic white (55%), black (28%), Hispanic (13%) or Asian (4%). Of the total study population, 8% started dialysis on PD and 0.1% started on home hemodialysis.
An unadjusted analysis (consisting of only race/ethnicity) was conducted, followed by adjustments for demographics (age, sex and year of dialysis initiation), medical factors and socioeconomic factors (including individual-, zip code- and hospital service area-level factors and regional provider culture).
Researchers found that, in the unadjusted analysis, black patients were 30% less likely and Hispanic patients were 19% less likely than white patients to start on PD (on the other hand, Asian patients were 31% more likely than white patients to start on PD).
After adjusting for socioeconomic factors, these differences were reduced by 13% between white patients and black patients, 28% between white patients and Hispanic patients, and 1% between white patients and Asian patients. Researchers noted black and Hispanic patients were less likely to receive a referral to a nephrologist before starting dialysis (care which was found to be strongly associated with PD initiation), while all three minority groups were more likely to be unemployed. Black and Hispanic patients also had higher rates of being uninsured and were more likely to live in poorer neighborhoods with lower levels of educational attainment.
The researchers wrote that despite the gap between white patients and minority patients narrowing after adjustments, black patients were still 24% less likely and Hispanic patients were 10% less likely to start dialysis with PD.
According to Shen, these results indicate a need for further research regarding what culturally specific differences in patient or provider preference for home dialysis might also be driving these disparities in home dialysis use.
Still, she said, “Knowing that adjustment for socioeconomic factors narrows the gap in home dialysis use among different racial and ethnic groups will help inform interventions to address these disparities.”
To this end, she proposed focusing on growing urgent-start PD programs and transitional care units, both of which, she argued, “have been proven to increase home dialysis use in socioeconomically disadvantaged neighborhoods where black and Hispanic patients disproportionately live.” In addition to helping close racial and ethnic gaps in home dialysis use, she said such interventions would “work towards meeting the U.S. goal of having 80% of incident patients with end-stage kidney disease be either on home dialysis or transplanted by 2025.”
She added that patient preference should be the most important factor in the selection of dialysis modality.
“It is important that we work towards providing equal access to every type of dialysis modality for patients of all backgrounds,” she said. – by Melissa J. Webb
Disclosure: Shen reports receiving personal fees from Baxter.