Credit: Original article published here.
Patients with glomerular disease may experience acute medical complications such as anasarca, infections, acute kidney injury, thromboembolism, and cardiovascualr events that require utilization of acute care (emergency department [ED] visit or hospitalization). In addition, patients with glomerular disease being treated with immunosuppressive therapies commonly experience infections that can result in utilization of acute care.
According to Jill R. Krissberg, MD, MS, and colleagues, the risk of utilization of acute care may be affected by race, ethnicity, and socioeconomic status (SES). The researchers conducted a prospective cohort study designed to compare rates of acute care utilization across racial and ethnic groups in adults and children with glomerular disease in the CureGN (Cure Glomerulonephropathy) cohort. They sought to test the hypothesis that rates of acute care utilization would be increased among Black or Hispanic patients but that lower SES and more severe glomerular disease in those groups would explain any observed differences. Results of the study were reported in the American Journal of Kidney Diseases [2023;81(3):318-328].
The study cohort included 1456 adults and 768 children with biopsy-proven glomerular disease enrolled in the CureGN cohort. The study exposure was race and ethnicity as a participant-reported social factor. Race and ethnicity were categorized as White, including non-Hispanic White; Black, including participants of Black race and any ethnicity; Asian, including participants of Asian race and any ethnicity; and Hispanic, including Hispanic White. The outcome of interest was acute care utilization defined as hospitalizations or visits to the ED.
Associations between race and ethnicity and utilization of acute care were estimated using multivariable recurrent event proportional rate models. The analyses were serially adjusted for confounders using six sequential models: the first model examined unadjusted associations between race and ethnicity and utilization of acute care; the second model additionally adjusted for demographic characteristics; the third model additionally adjusted for socioeconomic factors; the fourth for chronic disease indicators; the fifth for disease severity and activity markers at enrollment; and in the sixth model, estimated glomerular filtration rate (eGFR) was incorporated as a time-varying covariate.
Of the 1456 adults in the study, 65% (n=950) were non-Hispanic White, 16% (n=233) were Black (of which 14 were Hispanic), 11% (n=154) were Asian (of which none were Hispanic), and 8% (n=119) were Hispanic White. Compared with the adults who were White or Asian, those who were Black or Hispanic were less likely to have a college education, more likely to have US public insurance, and more likely to be on medical leave, disabled, or unemployed.
Black adults had the highest frequency of focal segmental glomerulosclerosis (FSGS) (45%); Asian and Hispanic adults had the highest frequency of immunoglobulin A nephropathy/vasculitis (39%-40%). Hispanic adults had the lowest eGFR, and Black adults had the highest urinary protein-creatinine ratio (UPCR). Black adults were most likely to have obesity, and Asian adults were least likely to have obesity or hypertension. The racial and ethnic groups were similar in frequency of use of glucocorticoid or other immunosuppression at enrollment. A family history of kidney disease was most likely among Black adults.
Of the 768 children in the study, 66% (n=507) were non-Hispanic White, 18% (n=141) were Black (of whom four were Hispanic), 6% (n=48) were Asian (one of whom was Hispanic), and 10% (n=72) were Hispanic White. Compared with White or Asian children, Black or Hispanic children were less likely to have US private insurance (59%, 50%, 34%, 34%, respectively). The parents of Black or Hispanic children were less likely to be college educated compared with the parents of White or Asian children.
The frequent diagnosis overall was minimal change disease, but Black children were most likely to have FSGS. Black children had the lowest eGFR and highest UPCR. Obesity, hypertension, or a family history of kidney disease were more likely in Black or Hispanic children than in the other racial/ethnic groups. Frequency of use of glucocorticoid or other immunosuppression at enrollment was similar across racial and ethnic groups.
The highest rates of acute care utilization were among Black adults, and the lowest were among Asian adults (45.6 events per 100 person-years vs 29.5 for Hispanic adults, 25.8 for White adults, and 19.2 for Asian adults; P<.001). The rates of acute care utilization were higher overall in children. The rates of acute care utilization in Black, Hispanic, White, and Asian children were 55.8, 42.5, 40.8, and 13.0 per 100 person-years, respectively; P<.001. The rates of intensive care utilization were higher in Black or Hispanic children compared with White or Asian children.
In unadjusted analysis, there was an association between Black race and a higher rate of acute care utilization compared with White race (rate ratio [RR], 1.76; 95% CI, 1.37-2.25) in adults. Following multivariable adjustment, the effect was attenuated but remained statistically significant (RR, 1.31; 95% CI, 1.03-1.68). There were no statistically significant differences between Hispanic and non-Hispanic White adults in rates of acute care utilization.
There was no significant association between Black race and acute care utilization in children; there was a significant association between Asian race and lower acute care utilization (RR, 0.32; 95% CI, 0.14-0.70). There were no significant associations between Hispanic ethnicity and acute care utilization observed.
The researchers cited some limitations to the study findings, including a lack of complete data for all participants, using indirect measures of SES, including only eGFR as a time-updated variable in the final model, and the use of ED for acute care that may reflect limited clinic hours of specialty care.
In conclusion, the authors said, “In this large, multinational cohort study of adults and children with glomerular disease, Black race was associated with higher rates of acute care utilization in adults and Asian race was associated with lower rates of acute utilization in children, even after adjusting for racial and ethnic differences in SES and disease characteristics. Addressing socioeconomic barriers to accessing and adhering to treatment and determining the influence of race and ethnicity on treatment effectiveness might help to minimize health care disparities.”
Takeaway Points
- Researchers reported results of a prospective cohort study examining the effects of race, ethnicity, socioeconomic status, and disease severity on utilization of acute care in patients with glomerular disease.
- In adults, there was a significant association between Black race and acute care utilization; a finding that was somewhat attenuated after multivariable adjustment but remained statistically significant.
- In children, there was a significant association between Asian race and lower rates of acute care utilization.
