September 21, 2020 • 7 min read
KATHLEEN BELMONTE, MS, RN, FNP-BC, MBA • DUGAN MADDUX, MD, PhD, FACP
Treatment and outcomes for chronic kidney disease (CKD) are dramatically affected by socioeconomic status. Not surprisingly, low-income countries are less likely to devote resources to CKD, but even in high-income countries, social determinants have a profound impact on the incidence and progression of CKD. Food insecurity, lack of transportation, and unstable housing are just some of the nonmedical factors that further complicate the lives and treatment of CKD patients. Societal inequality also increases the likelihood that people in low-income areas will develop kidney disease and other chronic conditions. To help break this cycle, Fresenius Medical Care is investing in programs that take a more holistic approach to both patient care and disease prevention.
Kidney disease is a global health problem. An estimated 750 million people worldwide experience kidney disease as either acute kidney injury or chronic kidney disease (CKD).1 Awareness, treatment, and outcomes for kidney disease reflect global variability and disparities along the continuum of low- to high-income countries. Such disparities are created by country-specific socioeconomic, cultural, and political factors.
A 2017 report by the International Society of Nephrology illustrates stark contrasts between low-income and high-income countries relative to kidney disease care.2 Screening for CKD occurs in 32 percent of high-income countries but only 6 percent of low-income countries. Government funding for CKD care is available in 53 percent of high-income countries, but only 13 percent of low-income countries. Data collection, disease registries, and research are more common in countries with financial resources for healthcare. Compared with high-income countries, poorer countries are less likely to screen for, prevent, and recognize CKD, and they are less likely to provide renal replacement therapies including dialysis and kidney transplant.
Global disparities in kidney disease prevention, occurrence, and treatment mirror disparities within high-income countries. In the United States, people living in areas of poverty and low socioeconomic status are disproportionately affected by CKD and CKD progression.3,4 Neighborhoods and communities experiencing socioeconomic challenges have a disproportionate incidence of people with CKD risk factors, including diabetes mellitus, high blood pressure, unhealthy lifestyle, and dietary patterns.5,6 Socioeconomic deficits lead to daily challenges that result in poorer health outcomes (Figure 1).7,8
Figure 1 | Medical impact of the daily challenges of people with socioeconomic deficits
When aggregated, studies on the connection of social disadvantage with CKD show a disproportionate disease impact in areas where people experience9
Such disadvantages result in poorer access to healthcare resources and specialty care including nephrology, creating “CKD hotspots”—communities at increased risk for CKD and end-stage kidney disease (ESKD).10 Socially challenged communities have a greater incidence of abnormal urine protein (albuminuria), greater prevalence of diabetes, and higher blood pressure compared with communities of people with more financial resources.11,12 People residing in low socioeconomic areas are less likely to benefit from CKD nephrology or multidisciplinary care, which is associated with better CKD outcomes including decreased risk for developing ESKD.13,14,15,16
Sorting out CKD risk related to social determinants of health is complicated by the close relationship of minority and racial status to socioeconomic status. For example, in the United States the APOL1 genetic variant is more common in people with African American ancestry, and the presence of APOL1 genetic alleles increases the risk of albuminuria and CKD progression.17 African American minority communities are also more likely to have socioeconomic challenges, but recent studies suggest that socioeconomic status may be the greater influence for CKD outcomes affecting people, regardless of race and ethnicity.18
Poverty and CKD risk may also be bidirectional. Poor socioeconomic status is associated with CKD risk factors such as decreased access to care, environmental toxin exposure, dietary risk, bias in services and care, and stress. In addition, the presence of CKD negatively impacts a person’s ability to work and results in lower income. CKD and other chronic illnesses are associated with disabilities and a higher burden of healthcare costs in both time and money, which negatively impact socioeconomic status.19
Social determinants of health intersect with CKD in very specific ways. Studies show that unhoused adults have an increased risk of proteinuria, advanced CKD, hospital and emergency department visits, less nephrology care, and poorer CKD outcomes.20 Programs to improve housing for people with chronic health challenges have resulted in increased survival and decreased healthcare spending.21 In the United States, food insecurity manifested as overnutrition and obesity is associated with an increased risk of developing CKD and, if CKD is present, an increased risk of CKD progression to ESKD.22 Healthy diets rich in fruits and vegetables lower the risk of CKD progression and the need for renal replacement therapy.23,24
Healthcare leaders are publicly discussing the benefits of addressing nonmedical needs of vulnerable and socioeconomically challenged patients.25 The U.S. healthcare community is working on ways to bridge gaps that occur from underfunding social services and result in significant healthcare costs in dollars and patient mortality for socially challenged patient populations. Henry Ford Health System and partner health systems support a program creating job training and apprenticeships that result in improved income, education, and home ownership for vulnerable patients. Healthcare leaders suggest that it is appropriate for healthcare organizations to participate in housing hearings and zoning for vulnerable neighborhoods faced with alcohol and unhealthy food retail options. Healthcare organizations are analyzing data sets that combine health and social data to identify geographic areas that are at increased risk for healthcare needs and may benefit from combined social and health interventions.
Social determinants of health are the conditions in which people are born, grow, live, work, and age. They include factors like socioeconomic status, education, home and physical environment, employment, and social support networks, as well as access to healthcare. A person’s health is also determined, in part, by access to social and economic opportunities; the resources and supports available in their homes, neighborhoods, and communities; the quality of their schooling; their access to sanitary water, food, and air; and the nature of their social interactions and relationships. Social factors are at the root of inequality in healthcare. Addressing social determinants of health is crucial for improving patient health and reducing disparities in access to healthcare.26
Populations that are more likely to be poor, such as racial and ethnic minorities, often have lower educational levels and are fundamentally at greater risk of ill health than non-minority, non-poor, and better educated peers. Healthcare and social factors associated with such disparities relate directly to access to care, which is important because such access is believed to result in better health. Every day, clinicians across the healthcare spectrum experience how unmet social and economic needs are barriers to adherence, limit treatment options, and shape clinical interactions. Prioritizing one’s health can be difficult under the best of circumstances, but it can be so much harder when people struggle with numerous pressing issues—such as affording a safe place to live, tenuous employment, difficulty paying for healthy food, social isolation, and the stress of being a caregiver.27
Recognizing that social determinants have a tremendous impact on health outcomes of CKD and ESKD patients, Fresenius Medical Care North America (FMCNA) has made investments in programs and infrastructure to support socially disadvantaged patients.
Food insecurity and malnutrition are major drivers of poor health outcomes in patients with CKD and ESKD. Data on malnutrition, food insecurity, health outcomes, and costs demonstrate that medically tailored, nutritious food is a necessary component of outcome-driven, cost-effective healthcare.28 Following a 2019 FMCNA Medical Office Live event, several local Fresenius Kidney Care (FKC) clinics and registered dietitians partnered with community-based medically tailored food programs to develop renal-friendly meal menus for ESKD patients.
Patients with ESKD require renal replacement therapy to sustain life. Nearly 87 percent of FKC patients travel to a dialysis center three or more times a week for treatment. Many dialysis patients are dependent on public transportation or have contracted medical transportation services in order to get to the dialysis facility. Missing even one treatment can cause complications and jeopardize patient health.
The most commonly reported barriers to hemodialysis were inadequate and/or unreliable transportation. Patient recommendations to improve dialysis attendance included more accessible transportation.29 Transportation affordability is a major concern for many patients. Through a joint venture partnership announced in 2019 with Ambulnz, a North American transportation services company/provider, FKC has sought to improve access to affordable transportation for dialysis patients. Ambulnz services have been introduced in New York, Texas, and Tennessee, with additional markets planned for 2020.
HOME THERAPY MODALITIES
Home dialysis therapy, including peritoneal dialysis (PD) and home hemodialysis, are presently underused dialysis modalities in the United States. Home dialysis has been identified as a therapy that will lower cost of care while improving quality of care.
The Centers for Medicare and Medicaid Services has strongly endorsed the shift to home-based dialysis. New regulations, reimbursement policies, and legislation are accelerating progress toward this goal. FMCNA believes it can achieve a 25 percent home therapy modality penetration by 2022 and a 50 percent home therapy modality penetration by 2025. FMCNA is committed to developing groundbreaking technology and introducing innovation to impact the lives of people living with kidney disease and transform the delivery of home-based dialysis.
FMCNA is designing initiatives that integrate comprehensive delivery with value-based payment models, as well as address CKD and ESKD patients’ physical, mental, and social needs.
The Global Medical Office at Fresenius Medical Care has identified five focus areas of social determinants of health that directly relate to the functional status of with ESKD