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Dr Madeleine McDowell: CKD Hits Harder and Earlier in Socially Challenged Neighborhoods


The data show the average age of dialysis in the least vulnerable neighborhoods was 68.2 years old, but 59.4 years—almost a decade earlier—in the most vulnerable.

Madeleine McDowell, MD | Image Credit: LinkedIn

Madeleine McDowell, MD | Image Credit: LinkedIn

Rates of chronic kidney disease (CKD) and end-stage renal disease (ESRD) are drastically higher in socially challenged neighborhoods, recent research revealed.

In an interview with The American Journal of Managed Care® (AJMC®), senior principal of advanced analytics and informatics at Vizient, Madeleine McDowell, MD, shares insight on her study "Measuring Care Utilization and Quality for Those With Chronic Kidney Disease by Payer and Community Vulnerability," and the implications of the study's findings.

This is part 2 of a 2-part interview with McDowell.

This transcript has been edited lightly for clarity:

AJMC: How does this disparity impact resources and patient care in the health system?

McDowell: There are a couple of questions that we have about this. So, the average age of dialysis in the least vulnerable neighborhoods, the low VVI (Vizient Vulnerability Index) score neighborhoods, was 68.2 years old. In the most vulnerable, it was 59.4–almost a decade.

When you think about this, this could indicate that patients are getting sicker earlier and progressing faster because of lack of access to primary care, lack of access to early interventions, not getting on the correct medications to slow that progression, both for diabetes and hypertension, as well as directly for chronic kidney disease.

It could also mean that there could be a shorter life expectancy, which is also bringing the age down, that the mean age for dialysis is younger because people in these high social needs zip codes, or geographies, are not living as long and so that population skews younger.

Both of those are very concerning to be addressing and speak to the quality of life for people with dialysis 10 years younger, the quality of life is significantly compromised

AJMC: How have racially based thresholds for chronic kidney disease diagnosis contributed to the disparities observed in these populations?

McDowell: We were not able to study race in this specific study due to the data limitations on us from the QECP (Qualified Entity Certification Program), that was something we wanted to do. However, it was something we wanted to study, because in the literature, as you're pointing out, they have different normal values for different races, meaning that they intervene in terms of treatment of CKD at a later stage for African Americans based on what they consider a normal value. The value of the EGFR has to be higher. So, we weren't able to study that but we suspect that is contributing to the data that we're seeing based on VVI.

AJMC: What areas of research do you think need further exploration to better understand the underlying causes of the CKD Disparities?

McDowell: First of all, confirming that screening rates for kidney disease in high-risk populations need to be improved and that there's variation by neighborhood. Secondly, identifying what the barriers to screening are. Is it provider education? Is it patient insurance and payer? Is it appointment and access time? Is it variation in provider knowledge, etc? There's work to be done on that front to reduce the barriers to screening first and foremost.

Second, I think an interesting study would be looking at the differences in therapeutic intervention. So, differences in when medications are started, because we do know that they can slow down the progression to end-stage renal disease and dialysis–the SGLT2 inhibitors are showing promise of slowing that down significantly, ACE inhibitors also play a role here.

These drugs: are they being given at different rates and different stages of chronic kidney disease based on social determinants of health? Because that's something that could make a big difference in terms of preventing end-stage renal disease and dialysis altogether if these patients are treated properly.

And another area that we'd like to look at is, what is the disparity in terms of follow up care consultation by nephrologists. Is there a difference in pattern? Do primary care physicians also provide the same opportunities for therapeutic intervention at the same time as nephrologists? Is that care pathway different, and if so, what is the variation in types of patients that get to see a nephrologist for their care?

AJMC: Is there anything else that you wanted to highlight?

McDowell: I did want to highlight some good news in the paper which was that we did not find any disparities in terms of patients on the transplant list, or patients once on the transplant list, getting a renal transplant. So for a lot of the work that's been done in transplantation, we did not see disparities in terms of the VVI, that there were differences in terms of where the patients came from.


Vizient report on chronic kidney disease finds wide variation in rate of screening among patient populations affecting outcomes. News release. Vizient Newsroom. August 29, 2023. Accessed October 2, 2023. https://newsroom.vizientinc.com/en-US/releases/releases-vizient-report-on-chronic-kidney-disease-finds-wide-variation-in-rate-of-screening-among-patient

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