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Frances E. Ferguson, M.D., MPH Program Director Office of Minority Health Research Coordination

Frances E. Ferguson, M.D., MPH Program Director Office of Minority Health Research Coordination National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health. Dr. Martin Luther King, Jr. - 1966.

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Frances E. Ferguson, M.D., MPH Program Director Office of Minority Health Research Coordination

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  1. Frances E. Ferguson, M.D., MPH Program Director Office of Minority Health Research Coordination National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health

  2. Dr. Martin Luther King, Jr. - 1966 “Of all the forms of inequality, injustice in health is the most shocking and inhumane.” HEALTH DISPARITIES

  3. The 2009 CMS/ESRD Network’s Annual Meeting April 08, 2009 Understanding Disparities in CKD: The Way Forward This presentation may possible in part by slide contributions from Dr. Keith C. Norris, MD, FASN Professor and Vice President for Research Charles R. Drew University of Medicine and Science, Dr. Andrew Narva, Director of the NIH National Kidney Disease Education Program, and from the USRDS

  4. Potential Conflicts of Interest*

  5. Objectives Identify CKD disparities in US Discuss mechanisms of selected contributors to CKD disparities in the US population Review results of interventions to reduce CKD disparities The Way Forward - suggested strategies for reducing disparities and future research directions

  6. What do we Mean by Disparities in CKD? Differences in clinical outcomes Gender, age, race/ethnicity, and geography Religion, politics, etc Genetic, physiologic, socio-cultural Opportunity to understand diverse factors that influence disease mechanisms and treatment response - & to make improvements May or may not be just or equitable Unjust is usually due to man made beliefs & systems

  7. Chronic kidney disease in the NHANES population USRDS 2008 Annual Data Report http://www.usrds.org/adr.htm

  8. Prevalence of GFR <60 ml/min/1.73m2, by time periodFigure 1.2 (Volume 1) NHANES participants age 20 & older

  9. Prevalence of microalbuminuria, by time period Figure 1.3 (Volume 1) NHANES participants age 20 & older

  10. Prevalence of GFR <60 ml/min/1.73m2 or microalbuminuria, by time period Figure 1.4 (Volume 1) NHANES participants age 20 & older

  11. Prevalence of CKD in NHANES participants, by identification method & CKD stage (percent of participants)Table 1.a (Volume 1) NHANES participants 1999–2006. Method One: standard method, using eGFR & microalbuminuria to define CKD. Method Two: gender-specific microalbuminuria used to define CKD. Method Three: same as Method One, but excluding pregnant women. Method Four: same as Method Two, but excluding pregnant women. *Estimate not reliable

  12. Despite a Lower Relative Prevalence of CKD there is a Higher Prevalence of ESRD in Minorities Relative prevalence of stage 1 - 3 CKD (MDRD GFR) Relative prevalence ofESRD Ref Ref Coresh J, et al. Am J Kidney Dis. 2003 Jan;41(1):1-12; USRDS 2002 Annual Data Report Hsu CY, et al. J Am Soc Nephrol 14 : 2902-2907, 2003

  13. ESRD in the United States

  14. Adjusted ESRD incident rates, by age & race/ethnicityFigure hp.3 (Volume 2) Incident ESRD patients; rates by age adjusted for gender & race; rates by race & ethnicity adjusted for age & gender.

  15. Adjusted ESRD incident rates(per million population) Table hp.a (Volume 2) Incident ESRD patients; rates by age adjusted for gender & race, rates by gender adjusted for age & race, & rates by race & ethnicity adjusted for age & gender. Rates for non-Hispanics are unadjusted. *Census data are not available for non-Hispanic blacks & whites, so rates cannot be calculated. For Hispanic patients we present data beginning in 1996, the first full year after the April 1995 introduction of the revised Medical Evidence form, which contains more specific questions on race & ethnicity.

  16. Age-Adjusted Prevalence of Diabetes* by Race/Ethnicity in the US American Indians/ Alaska Natives Non-HispanicBlacks Hispanic/Latino Americans Non-Hispanic/Whites 19% 15% 2-3X Higher 14% 7% Percent * In people 20+ years old. 1997-1999 National Health Interview Survey and 1988-1994 National Health and Nutrition Examination Survey (NHANES) estimates projected to year 2000. 1998 outpatient database of the Indian Health Service. CDC. National Diabetes Fact Sheet. 2002.

  17. Ethnic Differences in Hypertension Prevalence (NHANES 1999-2000) Ethnic Differences in Hypertension Control (NHANES 1999-2000) Percent Ethnic Differences in Hypertension Age-Adjusted Prevalence of Hypertension (%) Hajar and Kotchen. JAMA. 2003;290(2):199-206.

  18. Racial Differences in Estimated GFR Decline by BP Level 8 Estimated rate of GFR Decline ml/min/yr 6 Black 4 White 2 (Goal BP: MAP <92 ?) 0 <85 >90 mm Hg 85-90 Mean DBP Adapted from Kusek et al. JASN 4: 253, 1993, Toto et al Kidney Int 1995; 48:851-859, Walker WG, et al. JAMA 1992;268(21):3085-3091 & Klahr, S, et al.. New Engl J Med 1994;330:877-84

  19. BP Response to Antihypertensive Rx Among Whites and Blacks (Shaded area represents whites and blacks who have similar responses) Fifteen studies: 9,307 white and 2,902 black subjects. Similar changes to drug therapy 81-95% for DBP 83-93% for SBP ቓ 81-95% for DBP 83-93% for SBP Sehgal AR. Overlap between whites and blacks in response to antihypertensive drugs.Hypertension. 2004 Mar;43(3):566-72

  20. Disparities in Mortality: A Door to New Insights? Relative Risk of ESRD Mortality (2003) HTN Mortality Rate by Race & Gender (2003) 3 fold difference! HTN Mortality Rate (%) White African American Thom T, et al. Heart disease and stroke statistics--2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006 Feb 14;113(6):e85-151. USRDS 2006

  21. All-cause & cardiovascular mortality rates in prevalent ESRD patients, by race/ethnicityFigure hp.6 (Volume 2) illi illi lla lla Period prevalent ESRD patients; unadjusted. For Hispanic patients we present data beginning in 1996, the first full year after the April 1995 introduction of the revised Medical Evidence form, which contains more specific questions on race & ethnicity.

  22. Cardiovascular mortality rates in prevalent ESRD patients (deaths per 1,000 patient years at risk) Table hp.b (Volume 2) Period prevalent ESRD patients; unadjusted. For Hispanic patients we present data beginning in 1996, the first full year after the April 1995 introduction of the revised Medical Evidence form, which contains more specific questions on race & ethnicity.

  23. What do we Mean by Disparities in CKD (Norris K and Nissenson AR. J Am Soc Nephrol. 2008) Adapted from Smedley BD, et al. Washington, D.C.: National Academy Press, 2003

  24. Biologic Factors (Hereditary and/or Environmentally Influenced) Increased rates of hypertension and diabetes. Accelerated vascular damage (typically characterized by excess rates of albuminuria) due to increased rates of stress, nutritional deficiencies, toxin exposures, and other. Racial/ethnic variations in select enzyme activity, gene expressions, receptor densities and/or polymorphisms, for an array of signaling and metabolic pathways that may affect ESRD progression (eg, increased TGF-β, dysregulation of intrarenal renin-angiotensin system).

  25. Societal and Patient Level Factors (1) Institutional Racism and Residential Segregation Increased wealth disparity, lack of community resources, > cost for lower quality goods, lower quality education Increased crime, fewer public services Higher rates of environmental toxins < physicians, clinics, etc.

  26. Societal and Patient Level Factors (Con’t) • High rates of un- or under-employment • Poverty, lack of insurance • Urban or Ghetto Miasma • “invisible vapor of doom” • Weathering • stress of being poor & marginalized in America Williams DR, Jackson PB. Social sources of racial disparities in health. Health Aff (Millwood). 2005 Mar-Apr;24(2):325-34. Fiscella K, Williams DR. Health disparities based on socioeconomic inequities: implications for urban health care. Acad Med. 2004 Dec;79(12):1139-47. Helen Epstein Ghetto Miasma; Enough To Make You Sick? NY Times. October 12, 2003

  27. Literacy 48% of U.S. adults cannot read well enough to use a bus schedule The L.A. Workforce Literacy Project, 2004

  28. Societal and Patient Level Factors (2) Increased stress and/or depression, low self esteem, reduced personal responsibility related to above, often manifests as maladaptive coping behaviors (eg, overeating, drinking, smoking, substance abuse), increased nocturnal blood pressure, sympathetic activity, and oxidative stress. Cultural conflicts and linguistic barriers which may be perceived by providers or healthcare systems as patient insolence or ignorance; limits trust and effective communication, reduces adherence, and may influence health recommendations or availability of services.

  29. We don't see things as they are, we see them as we are. - Anais Nin (1903-1977)

  30. Healthcare Systems Level Factors Multiple payers and non-uniform provider incentives lead to marked variations in quality of care. Paucity of evidence-based data for clinical response to pharmacologic interventions among women and minorities who are under-represented in most trials.

  31. Uninsured by Race/Ethnicity (2001, adults 18-64) % Key facts. Race Ethnicity and Medical Care; Kaiser Foundation, 2003

  32. Access to Care: Effect of Single Payer System on CV Procedure Rates Among ESRD Patients Rate per 1000 person years Tarver-Carr ME, Powe NR, Eberhardt MS, et al: J Am Soc Nephrol 13:2363–2370, 2002

  33. A framework for integrating key socio-cultural determinants of CKD • Norris K and Nissenson AR. Race, gender, and socioeconomic disparities in CKD in the United States. • J Am Soc Nephrol 2008;19:1261-1270.

  34. The Way Forward Improved Provider-Patient Communication Evidenced Based Approaches Increasing Access to Care Minimizing Adverse Social Determinants of Health Re-conceptualization of Health and Health Care Disease mechanisms, modifiers, etc. Health beliefs and practices Gene-Environment interactions Mind-Body-Spirit

  35. World Health Organization Closing the Health Gap in a Generation Improve the conditions of daily life – the circumstances in which people are born, grow, live, work, and age. Tackle the inequitable distribution of power, money, and resources – the structural drivers of those conditions of daily life – globally, nationally, and locally. Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health. CSDH (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization.

  36. It is much more important to know what sort of a patient has a disease, than what sort of disease a patient has. -William Osler

  37. CKD: A Call to Action • Universal access to care, • (chronic care model) • Patient centered approach with • sensitivity to the nation’s cultural diversity • Automated GFR reporting • Early nephrology referral for co-management • -Renal care team approach to • maximize care • Small area analysis to identify community specific needs • Advocacy for social & health justice • Increased organ donation, especially from minority communities Patient-Provider Level Health Care System • CKD risk factor education • with targeted early interventions for • high-risk individuals • - Increased awareness of cultural differences in primary values, world views • Effective communication • Understanding socio-cultural & biologic • contributions to health disparities Community Level • Adapted from Norris K and Nissenson AR. Race, gender, and socioeconomic disparities in CKD in the United States. J Am Soc Nephrol 2008;19:1261-1270.

  38. Improving CKD Care, 2008 • Rettig RA, Norris KC, Nissenson AR. Chronic Kidney Disease in the United States: A Public Policy Imperative. Clin J Am Soc Nephrol. 2008 Oct 15. [Epub ahead of print]

  39. Improving CKD Care, 2008 • Rettig RA, Norris KC, Nissenson AR. Chronic Kidney Disease in the United States: A Public Policy Imperative. Clin J Am Soc Nephrol. 2008 Oct 15. [Epub ahead of print]

  40. Improving CKD Care, 2008 • Rettig RA, Norris KC, Nissenson AR. Chronic Kidney Disease in the United States: A Public Policy Imperative. Clin J Am Soc Nephrol. 2008 Oct 15. [Epub ahead of print]

  41. Improving CKD Care, 2008 • Rettig RA, Norris KC, Nissenson AR. Chronic Kidney Disease in the United States: A Public Policy Imperative. Clin J Am Soc Nephrol. 2008 Oct 15. [Epub ahead of print]

  42. CKD: A Call to Action • Universal access to care, • (chronic care model) • Patient centered approach with • sensitivity to the nation’s cultural diversity • Automated GFR reporting • Early nephrology referral for co-management • -Renal care team approach to • maximize care • Small area analysis to identify community specific needs • Advocacy for social & health justice • Increased organ donation, especially from minority communities Patient-Provider Level Health Care System • CKD risk factor education • with targeted early interventions for • high-risk individuals • - Increased awareness of cultural differences in primary values, world views • Effective communication • Understanding socio-cultural & biologic • contributions to health disparities Community Level • Adapted from Norris K and Nissenson AR. Race, gender, and socioeconomic disparities in CKD in the United States. J Am Soc Nephrol 2008;19:1261-1270.

  43. Wagner EH. Eff Clin Pract. 1998;1:2-4

  44. The Chronic Care Model (CCM) Summarizes basic elements for improving care in health systems (community, organization, practice, patient levels) Originated from a synthesis of scientific literature done by MacColl Institute for Healthcare Innovation in early 1990s Extensively reviewed by advisory panel of experts; compared with features of leading U.S. chronic illness management programs Refined and published in its current form in 1998 Improving Chronic Illness Care, a national program of RWJF, launched in 1998 with CCM at its core ICIC and Institute for Healthcare Improvement developed the Chronic Care Breakthrough Series Collaboratives, which gave rise to HSRA’s Health Disparities Collaboratives

  45. Chronic Care Model • Self-Management Support • Empower and prepare patients to manage their own disease • Delivery System Design • Assure the delivery of effective, efficient clinical care and self-management support • Decision Support • Promote care consistent with scientific data and patient preferences • Clinical Information Systems • Organize data to facilitate efficient and effective care

  46. The National Kidney Disease Education Program NKDEP aims to reduce the morbidity and mortality caused by kidney disease and its complications by: Improving early detection of CKD Facilitating identification of patients at greatest risk for progression to kidney failure Promoting evidence-based interventions to slow progression of kidney disease Supporting the coordination of Federal responses to CKD

  47. The Secret of the Care of the Patient is Caring for the Patient -Francis Peabody, 1927

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