Improving clinical care is only one element of the 360-degree, holistic treatment that is necessary to achieve patient equity, not equality, in patients with chronic kidney disease. Biology, lifestyle, and socioeconomic status are 3 areas in which inequities often have a particularly negative impact on a carefully constructed care plan.
A recently published study in JAMA Network Open asked: “Are there differences in guideline-recommended care delivery for chronic kidney disease (CKD) by race and ethnicity?”
The resulting findings showed that although there was higher performance on CKD care process measures among Asian, Black, and Hispanic individuals, these patients demonstrated similar or poorer outcomes in blood pressure and diabetes control compared with White patients. The study’s conclusion demonstrates that equal care delivery processes will not reduce longstanding racial disparities in CKD treatment. So, what do we need to do differently?
Improving clinical care is only one element of the 360-degree, holistic treatment that is necessary to achieve patient equity, not equality, in patients with CKD. Although the “one pill fits all” concept is a common practice, in reality, this is not an effective way of managing illness.
Imagine 2 patients with the exact same care plan. One patient understands how and why each prescribed element works together to slow the progression of kidney disease and has the resources needed to consistently follow the care plan daily. The second patient does not understand how the care plan will change the way he feels and lacks the resources to secure consistently nutritional meals and conduct regular monitoring.
Both patients received equal clinical guidance from their physician, but did they receive equitable care? No. And their outcomes will reflect this lack of equity.
The first step in closing the racial gap is to identify the areas in which inequities often have a particularly negative impact on a carefully constructed care plan. A patient’s biology, lifestyle, and socioeconomic status are 3 categories that immediately come to mind.
We know from medical literature that factors affecting kidney disease include rapid progression from comorbidities such as high blood pressure and diabetes, which are exacerbated by a poor diet and improper medication. However, blood pressure, diabetes, and medication are all elements that tend to respond and behave differently in different people and are often particularly variable when it comes down to genetics and race.
As an example, for African American patients with hypertension, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are not included in the recommendation for first-line therapy in the ACC/AHA and JNC guidelines compared with other groups. The guidelines base these recommendations on studies that have demonstrated different outcomes with particular antihypertensive medication classes in African American patients compared with other patient groups.
Another example of biological differences is the impact of the DASH diet intervention, which has been associated with a greater reduction in blood pressure in African American patients than in White patients.
Biological factors demand that we must examine the way in which comorbidities are already affecting the patient before prescribing additional medications appropriately, and the medications must also be carefully evaluated in terms of the patient’s genetics and race.
Physicians must also consider the diet and lifestyle of patients with CKD as significant factors impacting a care plan. For example, in the Asian community, carbohydrates traditionally play a much bigger role in meals than they do in White households. A traditional American meal includes vegetables, protein, and some carbohydrates on the side, not as a main dish.
Education in nutrition needs to be tailored to individual cultures, and part of a doctor’s job is to be sensitive to these cultural differences and offer alternatives that are accessible and palatable for the patient. Nutrition is extremely important in slowing the progression of kidney disease, but a “healthy meal” to one ethnicity can be vastly different for another.
Another key area outside of medication adherence is education; the patient must understand the disease process. Patients may fail to comply with their prescribed regimen because they do not have full understanding of their disease process. A patient who understands how each element of the care plan works together to control and slow the progression of CKD will feel empowered by this knowledge and have more motivation as results are realized.
However, access to information, and the ability to understand the disease process, can be difficult to achieve in certain socioeconomic environments and we must use our resources to combat this lack of equity.
Additional factors of socioeconomic status include accessing transportation to get to appointments, or the ability to afford healthy food. Stress level, worry over financials, and other psychological factors can actually affect a person’s body chemistry—so even if medication is taken exactly as prescribed, these factors can cause less than optimal results.
We have a long way to go before we close the racial gap in CKD, but the first step is an awareness that equity, not equality, should be our goal. Each patient is a unique individual. Doctors must get to know the patient on a personal level and identify the challenges and barriers that may disrupt a carefully developed care plan.
Utilizing available resources such as value-based services, local volunteer groups, and community health workers will provide an extended support structure for the patient. By taking the time to recognize and understand each patient, we can work together to create a health care system that provides equitable support and care for all races.