Dr Madeleine McDowell Discusses How CKD Disparities, Social Challenges Impact Health Care Access


Madeleine McDowell, MD, hopes these data insights will help change providers' behavior in terms of adopting earlier and more regular screening for chronic kidney disease (CKD).

Madeleine McDowell, MD | Image Credit: LinkedIn

Madeleine McDowell, MD | Image Credit: LinkedIn

Madeleine McDowell, MD, senior principal of advanced analytics and informatics at Vizient discusses the disparities observed in recent research on chronic kidney disease (CKD) in socially challenged neighborhoods compared with non–socially challenged neighborhoods.

The report "Measuring Care Utilization and Quality for Those With Chronic Kidney Disease by Payer and Community Vulnerability," shows various data demonstrating gaps in care. However, when evaluating those within the same city, the prevalence of dialysis was significantly higher in the most socially vulnerable neighborhoods.

This is part 1 of a 2-part interview with McDowell.

This transcript has been edited lightly for clarity:

The American Journal of Managed Care® (AJMC®): Can you share an overview of your research quantifying how the burden of CKD and end-stage renal disease (ESRD) disproportionately affects the most socially challenged neighborhoods?

McDowell: At Vizient, we applied to become a Medicare-qualified entity, which allows us to have 100% of Medicare fee-for-service claims data. In order to do that, you need to combine it with all payer data, so commercial and Medicaid. And in order to accomplish the full certification, you have to be able to demonstrate that you can produce a public report with the measures that are approved by Medicare. This paper was that.

This paper was our foray into becoming a QECP, a Qualified Entity Certification Program. We decided to look at CKD and ESRD, because they comprise a condition that is important to follow longitudinally, because it starts with a chronic condition, typically hypertension or diabetes, and progresses to the point of ESRD. So severity is significant, the costs are significant.

The prevalence is also increasing due to the rise in diabetes and hypertension. At the same time, there are many tools in our kit to prevent the progression. Both identifying early and treating hypertension, getting that blood pressure below 130 over 90, and treating it medically, and diabetes, treating early with both lifestyle changes and drugs.

In addition, there are medications that if given in the first 3 stages of CKD can significantly slow down the progression. So what we wanted to look at was, did the prevalence change based on social needs, social vulnerability, and where a patient lives geographically.

The Vizient Vulnerability Index (VVI) is an index that looks at the social determinants of health that impact overall health outcomes that was recently released to the public by Vizient. We were able to combine that VVI with the data to be able to identify if we saw differences in the prevalence, the progression of CKD and ESRD, by neighborhoods with high social vulnerability vs low.

We were querying the data. First, we chose these conditions, because they were high prevalence, they were high cost, and they were diseases that with intervention could be impacted greatly. Secondly, we had the VVI, and we wanted to be able to really tease out whether there were differences by neighborhood.

AJMC: Would you elaborate on the potential reasons behind the significant disparity in the prevalence of dialysis, ranging from 3- to 21- times higher, between neighborhoods with high social needs and those with the least social challenges?

McDowell: We were struck by the dramatic difference. Not struck by the trend—we were expecting to see something—but the trend was pretty dramatic in terms of the prevalence of dialysis patients in low VVI scores. So low-social-needs-score neighborhoods compared with high, and that prevalence ranged from 1.2 per 1000 beneficiaries to upwards of 8.9.

In addition to that, the average age of dialysis went down by 8.8 years in the highest vulnerable neighborhoods compared with the low-vulnerability neighborhoods. This tells us a couple of things. One, something's going on to lead to increased prevalence of dialysis, but also what that means is the progression of these common conditions, diabetes and hypertension, to CKD.

Then, CKD as stage 5 finally goes to stage 6, which is ESRD. The progression to ESRD is happening more often in high social needs ZIP codes. And it's happening sooner.

We could postulate that there are a couple of reasons why this is happening. One that would need to be tested is, the prevalence of diabetes and hypertension could be higher in these high-social-needs ZIP codes. What brings on diabetes typically is a sedentary lifestyle and not being able to exercise and diet, but there is a genetic component as well. However, generally, the metabolic conditions can be significantly improved with a healthy diet and exercise. So these are things that have been shown in other studies that can be challenging in high-social-needs ZIP codes, or neighborhoods.

There are a lot of factors for that. Sometimes just having access to outdoor spaces, safe spaces without crime, gyms, all of that can be limited for people from these neighborhoods. In addition to that, access to health care is also a question that we have in terms of, were these patients being seen regularly by their primary care doctor, were they screened for early signs of CKD using a simple blood test and estimated glomerular filtration rate? And were they screened at the same rate as people from other neighborhoods?

Then, other questions of, if they were put on the right medications—these are follow-up questions for other research projects—were they seen timely by a nephrologist or specialist? There are lots of questions that can be queried for follow-up.

But one thing we did see, also not surprising, was that in low-screening communities—so communities that were less than the 25th percentile in screening patients who had known diabetes and hypertension, screening them for CKD—those lowest screening rates in those communities also had the highest prevalence of CKD. Not surprising, as lower screening means you're not identifying those patients so they're not going to carry a diagnosis of that. But we think that's probably one of the main drivers.

We're hoping that these data insights will help change providers' behavior in terms of adopting earlier screening and more regular screening.


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.

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