Tseng C (DVA-Center for Healthcare Knowledge Management, VA New Jersey Health Care System, East Orange, NJ), Tiwari A
(DVA-Center for Healthcare Knowledge Management, VA New Jersey Health Care System, East Orange, NJ), Kern EF
(Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH), Miller D
(Bedford VA Medical Center, Center for Health Quality, Outcomes and Economic Research, Bedford, MA), Maney M
(DVA-Center for Healthcare Knowledge Management, VA New Jersey Health Care System, East Orange), Pogach L
(DVA-Center for Healthcare Knowledge Management, VA New Jersey Health Care System, East Orange)
About one in three veterans with diabetes have stage 3, 4, or 5 chronic kidney disease (CKD). The large majority of patients with CKD die without initiating renal replacement therapy, but the severity of CKD is independently associated with mortality risk. Although African Americans are more at risk of end-stage renal disease, it is unclear whether they are more at risk of pre-dialysis mortality. We sought to determine if there are racial disparities in dialysis-free mortality for patients with diabetes and advanced CKD.
This was a retrospective cohort study of Veterans Healthcare Administration clinic users with diabetes and stage 3-5 CKD, using a 12-month baseline period, and a 19.3 month median follow-up period during 1997-2000. The primary end-point was dialysis-free death.
Of 39,629 patients, there were 81.4% whites, 14.4% African Americans, and 2.2% Hispanics; another 2.0% were in other racial groups. Compared to whites (8.0%), all non-white racial groups had higher percentages of patients in stage 4 or 5 CKD: 13.3%, 11.6%, and 15.1%, respectively, for African American, Hispanics, and others. The overall dialysis-free mortality was 11.2 per 100 person-years, with 11.1, 11.6, 10.7, and 11.0 per 100 person-years, for whites, African Americans, Hispanics, and others, respectively. Adjusting for age and sex, the adjusted hazard ratios (AHRs) were 1.13 (95% CI=1.05, 1.21), 1.07 (0.90, 1.27), and 1.11 (0.93, 1.33), respectively, when African Americans, Hispanics, and others were compared to whites. The findings remained very similar when baseline covariates including VHA priority status, index eGFR, physical and mental comorbidities, sub-specialist care, and fact-to-face visits were added to the models. All non-white racial groups were less likely to visits cardiologists (24.0% vs. 34.1%) and endocrinologists (4.9% vs. 6.1%), but more likely to visit nephrologists (10.7% vs. 6.2%) than whites.
Among diabetic patients with moderately severe to severe CKD, African Americans were more at risk of dialysis-free mortality than whites.
Further evaluation is needed to determine if the differences in mortality in AA can be attributed to modifiable risk factors.