Racial Disparities in Acute Care Utilization Rates Among Children With Glomerular Disease

October 24, 2020

In reviewing the previous literature on health disparities in kidney disease, there is not a lot described in patients with kidney pathologies outside of ESKD and dialysis, said Jill Krissberg, MD, a pediatric nephrology fellow at Stanford University School of Medicine.

In reviewing the previous literature on health disparities in kidney disease, there is not a lot described in patients with kidney pathologies outside of ESKD and dialysis, said Jill Krissberg, MD, a pediatric nephrology fellow at Stanford University School of Medicine.

Transcript:

Why did you decide to investigate rates of acute care utilization across racial-ethnic groups in children with glomerular disease?

In reviewing the literature previously on health disparities in kidney disease, there's a lot described in end stage kidney disease (ESKD) and dialysis and transplant patients, but not a lot described in patients who have other kidney pathologies, those, say, who are at risk to go on and develop end stage kidney disease or who have glomerular disease, so diseases of the filters of the kidney itself that can get leaky and cause other problems. There's reason to believe there'd be disparities in those diseases. One, we know that African Americans are at increased risk of glomerular disease, because of the APOL 1 gene. Also these diseases impact patients' lives significantly, they often have a lot of complications, and the medications that they are required to take can also have a lot of complications like infections, blood clots, things like that, that would cause them to be in the hospital. With all of this in mind, there's reason to think that there are disparities that haven't been previously described before.

How did you go about conducting the study and what were the main findings?

We use the CureGN network. It's a large multinational prospective cohort study. It gives us a large sample with a diverse population to really study health disparities. Since glomerular disease is so rare, you need a lot of patients from a lot of different places to really have a large enough sample size to investigate these outcomes, especially when you're going to divide them amongst racial-ethnic groups. We had a nice database to look at. We did recurrent event proportional models to see how often they were getting admitted to the hospital or visiting the emergency room and seeing if there were differences in these rates across racial-ethnic groups.


Further, not just looking at the actual rates, but we wanted to understand what the causes would be of different rates if we were to see them. That's when we adjusted for confounders, and we did them sequentially so that we could understand what exactly the factors are that were causing differences that we saw. So, was it socioeconomic status, was it their overall health status? Was it the type of glomerular disease that they had? Or was it how severe their disease was?

We overall found that African American children did have increased rates of acute care utilization, so hospitalization or emergency department (ED) visits, but that is largely explained by their increased risk of having severe disease, in addition to their likelihood of being on public insurance. While there were differences amongst racial-ethnic groups, with Black children, being more likely to need acute care utilization, it is not inherent in race itself, but more because of their likelihood of having lower socioeconomic status and more severe disease.

Were any findings unexpected?

This is actually sort of what we hypothesized. I think it really speaks to the social determinants of health that we all know affect kidney disease. We know that race itself is a social construct, there's no genetic basis for race. There's nothing that's going to be inherent about the race that is going to make patients at risk for being hospitalized more. But it's really about the interplay of genetic propensity, their social factors, access to care, their socioeconomic status, health, literacy, etc, that all cause interplay of social determinants of health that lead to worse outcomes. I think this kind of proved what we were already suspecting but has given us a basis of how do we start intervening on these disparities to improve outcomes and make health more equitable.