Access to kidney transplant, CKD treatment affected by race, insurance status of the patient, study finds.

Access to getting a kidney transplant or early treatment for chronic kidney disease (CKD) is affected by the race and insurance status of the patient and only universal access to health care may overcome the disparities, according to two new studies published in the March issue of the Clinical Journal of the American Society of Nephrology.

In one of the two studies, Douglas Keith, MD, of McGill University in Montreal, Canada, and colleagues analyzed data on nearly 76,000 US patients wait-listed for a kidney transplant between 2001 and 2004. Their goal was to identify factors affecting time on dialysis before being placed on the waiting list for getting a transplant.

During the four-year study period, the researchers found:

*There was a significant increase in the rate of "pre-emptive listing" - being placed on the transplant waiting list before starting dialysis. However, the median time spent on dialysis before wait-listing was essentially unchanged.

*The rate of pre-emptive listing was lower, and time spent on dialysis was longer, for minority patients and for patients on Medicare (compared to those with private insurance);

*Less-educated patients and those whose kidney disease was caused by high blood pressure also had a reduced rate of pre-emptive wait-listing and a longer time on dialysis. On average, a minority patient who was on Medicare and had less than a high school education spent 20 times longer on dialysis before being wait-listed, compared to a Caucasian with private insurance and at least a high school education.

*The impact of insurance was greatly reduced after age 65. At that age, Medicare patients no longer have to go through a mandatory waiting period before being eligible for kidney transplantation. However, the disparities for racial and ethnic minorities and for less educated patients persisted after age 65.

"The most important issue for timely access to the waiting list is insurance or the lack of it," Keith commented. "Our study suggests that a universal system of insurance coverage would improve access for those most disadvantaged by the current insurance system."

In the second study, Sam Gao, MD, of the Naval Medical Center Portsmouth (VA) and colleagues analyzed the quality of care for more than 8,000 patients with moderate to advanced CKD treated in the Department of Defense (DOD) medical system. Their goal was to determine whether universal access to health services in the DOD system avoids racial disparities in CKD care.

The researchers said the results suggested that care provided to black patients with CKD in the DOD system was very similar to that provided white patients and, in some cases, measure of kidney care were higher for black patients. They did find, however, that one significant difference was lower monitoring of cholesterol levels among black patients.

"We were able to show that blacks and whites received similar care, unlike some other aspects of medicine in the United States where blacks receive less care than whites," Gao commented. "This may be due to universal access to care provided to all DOD beneficiaries."

In an editorial accompanying the two studies, Keith Norris, MD, of Charles Drew University (where) and Allen Nissenson, MD, of the David Geffen School of Medicine at UCLA in Los Angeles, CA, said the results should be seen as "yet another wake-up call as to how we as a medical community need to lead the health agenda for the nation, including the reduction and/or elimination of health disparities."

Norris and Nissenson called on the nephrology community to "take the opportunity as health leaders to ensure uniform health care to all citizens and move closer to eliminating the tragedy of health inequities, and the unacceptable morbidity and mortality associated with CKD."