Getting to the Root of Health Disparities in Kidney Disease

Across the United States, 15 percent of adults are estimated to have chronic kidney disease. This widespread disease doesn’t take an even toll, however.

“Kidney failure is common, but it’s up to 3.4 times greater in various racial and ethnic minorities, such as African Americans, Hispanics, and American Indians,” said Wendy St. Peter, PharmD, professor in the Pharmaceutical Care and Health Systems Department at the University of Minnesota’s College of Pharmacy. “We’re never going to get our hands around the issue of the progression of kidney disease unless we meet these health care disparities head on and address them.”

St. Peter and collaborator Rebecca Maxson, PharmD, associate clinical professor at the Harrison School of Pharmacy at Auburn University in Alabama, aim to do just that. Through their Advancing Kidney Health through Optimal Medication Management (AKHOMM) initiative, they are developing modules that can both train pharmacists and provide tools to educate patients to increase the safe and effective use of medications to treat the disease. Ultimately, they hope to see fewer patients reach the point where they need dialysis or a kidney transplant.

The project is supported by funding from the Office of Translational Grant Program at the University’s Office of Discovery and Translation.

While there is no cure for chronic kidney disease, effective treatment can help control symptoms, reduce complications, and slow the disease’s progression. When diagnosed early, treatment involves making lifestyle changes and taking medications to control symptoms. Later-stage kidney disease, however, requires either dialysis to remove waste products and extra fluid from the blood or a kidney transplant.

Providing specific medication-based treatment is a key tool to reduce disease progression, but it’s more complicated than it sounds. The workforce suffers from a shortage of kidney specialists (known as nephrologists), making it hard to provide for the large number who need care. In addition, patients tend to have several other conditions to manage at the same time, making treatment a more nuanced subject.

“Many patients have up to five other chronic disease alongside chronic kidney disease and are on an average of 10 medications per day,” Maxson said. “It’s a complex patient population. We’re not just treating one thing; we’re treating six things.”

Connecting with Patients

What exactly should the training and educational modules cover to help improve medication management? That’s the first question the researchers are working to answer. Their work will focus first on African American patients from diverse communities across the country.

Right now, St. Peter and Maxson are setting up three focus groups to gain insight from patients. One will be focused around African American patients who have chronic kidney disease in its earlier stages, where lifestyle changes and medications are the primary treatments. The second group will include African American patients whose disease stage is further along and who require dialysis or a transplant to survive. With each of these first two groups, they will ask patients about the barriers they see in accessing, understanding, and using the medications.

The final focus group will center on practitioners, whose input can help the researchers understand where they see barriers to helping patients manage their medications.

As the modules come together, St. Peter and Maxson are hoping to test their effectiveness at improving health outcomes in African American patients. If successful, St. Peter said the team will begin to think about how they can tweak these modules to reach other patient groups who face disparities in kidney disease, including members of the Hispanic population, the Hmong population, and the American Indian population. In every case, the process will begin with understanding patients’ perspectives.

“In the past, we’ve made assumption as practitioners for why treatment isn’t working, for why medications aren’t working, and for why patients aren’t taking their medication,” she said. “The key here is we’re using the patient voice in everything we’re doing.”

Bringing Pharmacists Aboard

In hospital settings, pharmacists are often included in care decisions, where they help select medications patients will benefit from, find less-expensive alternatives where appropriate, and refrain from using medications patients do not need. These choices help shorten hospital stays and reduce waste, saving money and benefiting patients’ health.

The same is not true of most outpatient care situations. Medicare typically does not cover pharmacists as part of a health care team (the way it would physicians, dietitians, or other experts), making it hard for pharmacists to offer their expertise for treatment decisions.

That standard may be changing, as the launch of the federal Advancing American Kidney Health initiative in 2019 included changes to the way the Centers for Medicare and Medicaid Services pay for kidney disease care in patients on Medicare. The new voluntary kidney care models focus on value-based measures like the rates of depression, reduction in total cost of care, patient involvement in managing their condition, and other factors—many of which pharmacist’s expertise can help to improve.

It’s an opportune time to better integrate pharmacists in the care process, St. Peter said.

“Our vision is that every patient with kidney disease receives optimal medication management through team-based care including a pharmacist,” she said. “The pharmacist is there to ensure medications are safe, effective, and convenient for them to use.”

Separate from the modules the researchers are working on, they are also organizing an opportunity to bring kidney doctors and pharmacists together to learn from one another. This peer-to-peer environment, called a learning and action collaborative, will allow the two professionals along with other health care team members to further improve medication management practices.

Maxson and UMN researcher Debbie Pestka, PharmD, PhD, adjunct assistant professor in the Department of Pharmaceutical Care and Health Systems in the College of Pharmacy, are conducting interviews with a number of the few pharmacists who do already work as part of kidney care teams, despite the current barriers, to learn from their experiences and lay the groundwork for this effort.

“In talking to these currently active pharmacists who are integrated with the team in the outpatient setting, we aim to find out what they are doing now that’s working really well, and then what they would like their practice to be in an ideal world,” Maxson said.