The D&T Report

The disparity in the burden and outcomes of chronic kidney disease (CKD) between whites and racial and ethnicminorities in the United States is well documented.1 There are several factors that may contribute to this discrepancy among specific groups. Blacks and Hispanics have genetic predispositions toward hypertension and diabetes, respectively. These populations as a whole, when compared with whites, are often comprised of a higher number of low-income families, more isolated or impoverished neighborhoods, and they often have less education and poorer access to healthcare. As a result, there are nearly 33% more minorities who receive renal replacement therapy than there are whites.2

Socioeconomic status may be even more important than racial or ethnic factors. In an analysis of data from the National Health and Nutrition Examination Survey, Rajnish Mehrotra, MD, a nephrologist and professor of medicine at the University of California, LosAngeles School of Medicine, and colleagues found that black and Hispanic patients with endstage renal disease (ESRD) who were younger than 65 had a significantly higher risk of mortality than their white counterparts. However, the difference became insignificant when the authors adjusted their calculations for socioeconomic and access- to-care variables.3 “What this tells me is that the higher risk for death [among black and Hispanic patients] is related to issues that can be summarized in terms of socioeconomic characteristics,” says Dr. Mehrotra. In other words, a large part of the difference relates to sociology rather than biology, he says.

Poverty may take a greater toll on blacks than on whites. Deidra Crews, MD, a nephrologist and associate professor of medicine at Johns Hopkins School of Medicine in Baltimore, and colleagues found that the prevalence of CKD was 27% higher among Baltimore residents with family incomes below the federal poverty level, as compared with those above it. However, blacks living below the poverty level were 33% more likely to have CKD than whites of similar income. 4 “Poverty may have a different impact on black than white patients in determining who's at risk for CKD,” says Dr. Crews. “One possible explanation is that, in an urban setting like ours, there may be some factors that affect blacks differentially over whites.”

In another study from Johns Hopkins, senior author L. Ebony Boulware, MD, MPH, and colleagues at the university's School of Public Health examined racial differences in sources of healthcare, health insurance, and incidence of CKD in 3,883 white and 1,607 black participants. The black patients were significantly less likely to have access to healthcare, and significantly more likely to have CKD. Adjustment for demographic, socioeconomic, lifestyle, and clinical factors accounted for 64% of that increased risk, and limited access to healthcare accounted for an additional 10%. Their conclusion: At least part of the racial disparity in CKD could be traced to poorer access to care.5

In short, numerous factors converge to produce the disparity. “It's lack of transportation to get to the doctor's office, and limited availability of doctors who will see these patients,” says Chester Fox, MD, professor of family medicine at the University of Buffalo, N.Y. “It's lack of child care. Often it's also lack of health insurance, but even if the patient has insurance, she may still lack the transportation to get to the doctor. Elderly patients have Medicare, but with all the copays and additional costs, they may not be able to afford themedications that control their diabetes and hypertension.”

Dr. Crews urges renal-care professionals to make a point of learning more about their patients' circumstances and change the things that can be changed, such as diet. “I often askmypatients who prepares the food in their household and where they get their groceries to get a sense of what's available to them, and then I make recommendations that are specifically tailored to their situation,” she says. For example, if patients do not live near a market that stocks fresh fruits and vegetables, she suggests that they consider frozen fruits and vegetables instead.

In addition, “continuing, ongoing, non-judgmental education has to be the central component when reaching out to patients and communities,” says Dr. Mehrotra. Doctors already have very effective preventive measures at their fingertips; the challenge is to maximize behaviors such as blood pressure and glucose control through repeated education. Patients often do not believe that they have a disease, or that they need dialysis, unless someone explains the silent nature of renal disease and shows them their lab results, says Bessie Young, MD, MPH, associate professor of medicine at the University ofWashington, Seattle.

Dr. Fox maintains that educating the primary care physicians for earlier recognition and treatment of risk factors is an important first step in reducing the disparities. “Emphasizing good blood pressure control is something we can do at the very early stages to help prevent CKD,” he says. “The same for diabetes care and reduction of obesity through healthier eating habits—these are preventive measures we can take early on to help reduce the disparities in renal disease seen in the population.”

Clinicians must be educated as well, says Dr.Young. “They need to learn about healthy diets and what's actually doable, and what exercise their patients can do, as well as the current recommendations for exercise, losing weight, and changing unhealthy habits,” she advises.

Racial and ethnic disparities in the burden of CKD are a proxy for the wider socioeconomic disparities that exist in the United States.Ameaningful solution will require attention to broad issues such as employment, education, and neighborhood resources. “Poverty is complicated,” Dr. Crews warns. “It's definitely more than just income.”

BellevueHospital inNewYork City, in conjunction with city fire and police departments, has started a six-month pilot program designed to increase organ donation after cardiac death (DCD). The program, launched in December, was started with the help of a grant from the U.S. Department of Health Resources and ServicesAdministration. Recognizing that the vast majority of deaths in the United States occur outside the hospital, the program sends an organdonation team to the home of a person who suffers a cardiac arrest. The team will arrive in a special “Organ Preservation Unit” vehicle (pictured above), but will not enter the home until the person has been declared dead. Once there, they will have about 20 minutes to determine whether or not the deceased is a suitable organ donor, see if their name is already in the organ donor registry, and convince the family to allow them to obtain their relative's organs.6

The program is the brainchild of Lewis Goldfrank, MD, professor and chair of Emergency Medicine at New York University Medical School, and resulted from his participation on a panel that was part of a 2006 Institute of Medicine conference entitled, “Organ Donation: Opportunities for Action.” His panel focused on ways of increasing the number of organ donors. Over the years, Dr. Goldfrank observed that many families of patients who died in the emergency department would offer to donate their loved one's organs, “and Iwould say, ‘We don't have a mechanism in this country for me to care for someone who's had a cardiac arrest and allow them to become a donor,”’ he says. “I would also see people with end-stage renal disease or liver disease who collapsed and died. So here you had people who were in desperate need of an organ, and other people whose loved ones thought they would be delighted to give an organ, but we didn't have a system for people with cardiac death to become donors.”After discovering that Spain and several other European countries routinely permitted DCD organ donation with good results, he began developing the Bellevue program.

<QD>This program will expand the opportunity for organ donation for both the donor and the donor's family.</QD>

—Dolph Chianchiano

The project had not yet obtained any patients as of Jan. 15. So far, the biggest obstacles have been logistical ones: seeing how long it takes for the vehicle to move through midtownManhattan traffic to the scene of the arrest, dealing with glitches like blizzards and problems in the radio call system, and finding patients who meet the eligibility criteria. “It's an immense educational process: there are many things we will learn that I thinkwill help the effort,” says Dr. Goldfrank. Members of the organ donation community are greeting the program with cautious optimism. “It's really imperative that every effort be made to save the life of the potential organ donor and be clear that he is no longer with us” before the team goes into a patient's home, says Dolph Chianchiano, senior vice president for Health Policy and Research of the National Kidney Foundation. With that caveat, he believes that “this program will expand the opportunity for organ donation for both the donor and the donor's family.”

“This project could really impact the number of people who are waiting for kidneys,” says Suzanne Conrad, immediate past president of the Association of Organ Procurement Organizations. “The reality is that right now in the United States, if you want to be an organ donor you have to die in the hospital. So this would expand the number of people who could become organ donors.”

If we're going to increase organ transplantation rates in the U.S., we're going to have to do something “revolutionary” like this, says Dr. Goldfrank. “I think many people believe this is what we have to do; we just have to see if it can be done.”

On December 29, CMS issued a final rule that details how, in 2012, Medicare will reduce payments to dialysis providers who failed to meet certain performance standards in 2010. The final rule, part of the CMS-mandated Quality Incentive Program (QIP), is being called the QIP Rule, and is the second leg of the significant changes to the Medicare payment methodology enacted by Congress in 2008. (The first of these changes, the prospective payment system, went into effect Jan. 1 of this year.) With the QIP Rule, CMS will implement the 2008 congressional mandate of “penalties for poor quality.” CMS contemplates that the QIP Rule will reduce the payments it would otherwise make in 2012 by $17.3 million. Under the rule, CMS will reduce by up to 2% the amounts that it would otherwise pay dialysis providers that, in 2010, failed to achieve a weighted score of at least 26 points out of amaximum score of 30 in three weighted quality measures. Providers that receive a score lower than 10 in the QIP Rule, called the Total Performance Score (TPS), will be penalized the full 2%. For scores between 11 and 25, the payment reductions are gradually increased in three increments of 0.5% each (Table I.) The payment reduction will apply to all payments by Medicare for 2012 dialysis services performed by the providers who are being penalized. In addition, the 20% co-payment requirement from Medicare beneficiaries will only apply to the reduced payment amount.

The TPS for each provider is based on the three weighted performance results (each, a “QIP Score”) that measure anemia management and hemodialysis adequacy results, with a maximum of 10 points assigned to each of the three QIP Scores, and each QIP Score assigned a relative weight. For each QIP Score, CMS will subtract two points for each percentage point by which the provider failed in 2010 to meet measurement standards for each QIP Score. For 2012 payment reductions, the measurement standards that will apply are the 2008 national standards for each performance result or the 2007 actual performance results of each provider, whichever are lower. (Table II)

CMS will notify dialysis providers of their TPS at least 30 days prior to its posting on the Dialysis Facility Compare website, and each provider will be required to post a copy of its score at each facility. Finally, the QIP Rule addresses its application to dialysis facilities that first became operational after 2007, have a very small number of patients, treat pediatric patients, or provide home dialysis services.

The policy will apply only to 2012. CMS indicates that it will likely expand and/or change the performance standards for 2013 and thereafter, and will use the measurement standards as “floors” to encourage dialysis providers to improve performance on a year-over-year basis. Moreover, CMS indicates that, in all likelihood, the 2013 QIP payment reductions will be based on 2011 performance as compared with the standards that apply for that payment year.