November 18, 2021
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After NKF/ASN task force report, CMS takes on equity issues

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It has been a busy time in the debate over equity in kidney care.

Our Cover Story in this issue details the development of the final report by the National Kidney Foundation and the American Society of Nephrology Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease. The 14-member work group began meeting in August 2020 and completed a final report in September, with their recommendations published jointly in the American Journal of Kidney Diseases and the Clinical Journal of the American Society of Nephrology.

The authors explained the rationale for the review this way:

Mark E. Neumann

“Recent attention to racism in society and the affirmation that race is a social construct has led to dialogue in the medical community about the use of race in algorithms used in clinical care,” the authors wrote. “ ... For [4] decades, in many of the areas where [estimated glomerular filtration rate] is used, disparities in care have been documented for underrepresented communities, especially Black or African American [individuals]. Because glomerular filtration is a biologic function, the use of race, a social construct, in its calculation has been questioned, including its contribution to existing disparities. The medical community has been engaged in dialogue about whether or how to expunge race from the equation.”

Testing the conclusions

The task force agreed that removing race from eGFR was the first step toward equitable access to care. By doing so, it would likely show that more Black individuals would be diagnosed sooner with early stages of chronic kidney disease – and more likely qualify for a kidney transplant.

“The biggest concern among the proponents to remove race from the original equation was whether or not this played a role in the decision to refer patients for transplantation,” Cynthia Delgado, MD, FASN, co-chair of the task force, told Nephrology News & Issues. “The cutoff would be different for African Americans compared to everyone else,” Delgado said.

Some medical centers have already tested out that theory. Results of a study by Vishal Duggal, MD, a post-doctoral fellow in medical informatics at the Veterans Affairs Palo Alto Heath Care System, and colleagues showed the prevalence of CKD among Black adults doubled when race adjustment was excluded from eGFR equations.

“Estimation of GFR without race adjustment reclassifies a sizeable fraction of Black adults with CKD. Because the race adjustment factor is constant and CKD prevalence is higher at earlier stages, its elimination leads to a larger effect on CKD prevalence at earlier vs. more advanced stages,” they wrote.

CMS pursues equity of care

Following release of the NKF-ASN task force report, CMS issued its final rule for the Prospective Payment System for CY 2022. The changes include new financial incentives to encourage dialysis providers in the End-Stage Renal Disease Treatment Choices (ETC) model to decrease disparities in rates of home dialysis and kidney transplants among ESRD patients with lower socioeconomic status.

“Today’s final rule is a decisive step to ensure people with Medicare with chronic kidney disease have easy access to quality care and convenient treatment options,” Chiquita Brooks-LaSure, CMS administrator, said in a press release. “Enabling dialysis providers to offer more dialysis treatment options for Medicare patients will catalyze better health outcomes, greater autonomy and better quality of life for all patients with kidney disease.”

Both these efforts are of value in assuring that all individuals with kidney disease are treated equitably. But Delgado noted a long path ahead remains.

“We still have African Americans who have the highest prevalence of hypertension,” she told Nephrology News & Issues. “We have kidney failure rates at three to four times greater in racial ethnic minorities compared [with] whites. And there is also a disparity in access to home therapies for treatment of ESRD.

“So there is definitely more work to be done.”