Skip to main content

Main menu

  • Home
  • Content
    • Published Ahead of Print
    • Current Issue
    • JASN Podcasts
    • Article Collections
    • Archives
    • Kidney Week Abstracts
    • Saved Searches
  • Authors
    • Submit a Manuscript
    • Author Resources
  • Editorial Team
  • Editorial Fellowship
    • Editorial Fellowship Team
    • Editorial Fellowship Application Process
  • More
    • About JASN
    • Advertising
    • Alerts
    • Feedback
    • Impact Factor
    • Reprints
    • Subscriptions
  • ASN Kidney News
  • Other
    • ASN Publications
    • CJASN
    • Kidney360
    • Kidney News Online
    • American Society of Nephrology

User menu

  • Subscribe
  • My alerts
  • Log in
  • My Cart

Search

  • Advanced search
American Society of Nephrology
  • Other
    • ASN Publications
    • CJASN
    • Kidney360
    • Kidney News Online
    • American Society of Nephrology
  • Subscribe
  • My alerts
  • Log in
  • My Cart
Advertisement
American Society of Nephrology

Advanced Search

  • Home
  • Content
    • Published Ahead of Print
    • Current Issue
    • JASN Podcasts
    • Article Collections
    • Archives
    • Kidney Week Abstracts
    • Saved Searches
  • Authors
    • Submit a Manuscript
    • Author Resources
  • Editorial Team
  • Editorial Fellowship
    • Editorial Fellowship Team
    • Editorial Fellowship Application Process
  • More
    • About JASN
    • Advertising
    • Alerts
    • Feedback
    • Impact Factor
    • Reprints
    • Subscriptions
  • ASN Kidney News
  • Follow JASN on Twitter
  • Visit ASN on Facebook
  • Follow JASN on RSS
  • Community Forum
PerspectiveSpecial Series on Addressing Racial and Ethnic Disparities in Kidney Disease
Open Access

Looking Upstream–The Role of Primary Care in Addressing US Race Inequities in Kidney Health

L. Ebony Boulware
JASN July 2022, 33 (7) 1249-1251; DOI: https://doi.org/10.1681/ASN.2021101289
L. Ebony Boulware
Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
Center for Community and Population Health Improvement, Clinical and Translational Science Institute, Duke University, Durham, North Carolina
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for L. Ebony Boulware
  • Article
  • Figures & Data Supps
  • Info & Metrics
  • View PDF
Loading
  • health inequity
  • race
  • primary care
  • primary health care
  • racial and ethnic disparities

Early evidence of racial inequities in kidney health frequently emerges in primary care settings. Despite this, the vast majority of attention to racial inequities in kidney health has been paid toward identifying and addressing inequities in late stages of kidney disease and specialty care, including a focus on racial inequities in the incidence of ESKD and inequities in utilization of, and access to, home therapies and kidney transplants. Although important, this nearly exclusive focus on racial inequities in late and end stage disease care detracts from efforts to identify, understand, and address the early contributing “root causes” for racial kidney health inequities, and it may impede efforts to meaningfully change their trajectory.

Multiple factors disproportionately disadvantage individuals who are racially minoritized with regard to health-promoting conditions (including social policies and systems, health care system processes, health care provider practice patterns, and patient attitudes or behaviors).1 In primary care, the focus of treatment is to prevent CKD incidence or slow its progression, primarily through the treatment of CKD risks. However, evidence suggests societal and health system policies that influence primary care, along with health care provider practices, may represent important potential contributors to racial inequities in kidney health.

For instance, a national study demonstrated that Black individuals were nearly 40% less likely than White individuals to receive recommended treatments for hypertension, one of the most commonly cited risk factors for ESKD—with racial differences in treatment predominantly evident among Black individuals who were uninsured.2 Similarly, lack of access to a usual source of primary care explained up to 10% of the excess risk of CKD incidence among Black individuals, when compared with White individuals, in a longitudinal study.3 Studies have also demonstrated associations of structurally mediated social disadvantage (including poverty and poor food availability) with racial inequities in kidney health.4 However, socially disadvantaged individuals with CKD risks may face significant barriers to seeking and receiving primary care because of a lack of affordability, accessibility, or availability of primary care services.5 Beyond structural factors, evidence suggests that, despite their knowledge of the importance of CKD prevention efforts, primary care providers who often care for individuals who are socially disadvantaged and minoritized may have difficulties prioritizing CKD above multiple other health priorities they are tasked with managing for patients at risk of CKD, particularly those with multimorbidity.6 Primary care providers may also lack skills to communicate with patients about CKD risks and prevention. For instance, a study conducted in an urban primary care clinic demonstrated that communication about CKD between Black individuals who were disadvantaged and their primary care physicians was often very brief, contained highly technical jargon, and was lacking with regard to ensuring patients were adequately educated or had a clear understanding of their CKD risks.7 Accordingly, Black patients at risk of CKD incidence or progression receiving care in similar settings have reported low perceived susceptibility to CKD.8 Individuals who are minoritized and socially disadvantaged have also reported numerous multifaceted barriers to CKD treatment self-management, including a lack of understanding of treatments, inadequate social support, and financial (e.g., income and insurance) needs.9

If we are sincere in our intent to eliminate racial inequities in kidney health, it is crucial that we target the compounded effects of societal, health system, health care provider, and patient-level contributors to racial inequities that emerge in primary care. A new era of studies that will generate the evidence needed to target mechanisms at each of these levels is needed (Table 1). For instance, studies should examine how policies directly targeted toward health and health care delivery (e.g., health insurance policies) and policies not directly targeted toward health and health care (e.g., policies to reduce the effects of poverty) can be leveraged to improve CKD prevention and treatment in primary care. Interventions to address contextual barriers that individuals face in their communities (e.g., living conditions, transportation to and from care, proximity and availability of care, and the presence of health-promoting environments) must also be studied. Studies should also identify innovative models that redesign primary care to improve the effectiveness in CKD prevention and treatment, including models that seek to extend the reach and influence of primary care services through the work of allied health professionals (e.g., social workers) and lay health professionals (e.g., community health workers or health navigators). Evidence-based best practices that will help primary health care practitioners prioritize CKD as an important contributor to poor health outcomes among individuals who are disadvantaged, particularly those with multiple CKD risk factors, are also needed. Finally, more research is needed to identify mechanisms to best support individual patients as they seek to overcome social, contextual, and health system barriers to care. These new investigations should be conducted with an eye toward sustained, real-world implementation and will, therefore, likely require new partnerships (e.g., with policy makers, community-based organizations, public health agencies) to maximize their relevance and effect.

View this table:
  • View inline
  • View popup
Table 1.

Example questions to be addressed to target multilevel influences on kidney health inequities in primary care

As we embark on new work to address these and related questions, early evidence provides hope that innovative interventions targeting the upstream “root causes” of racial inequities could make a difference. For instance, a study among socially disadvantaged Black individuals at risk of CKD incidence or progression who received primary care in an urban clinic demonstrated substantial BP improvements when community health workers were incorporated into patients’ care.10 Similarly, a study that targeted primary care physicians’ practices in a safety-net health care delivery system demonstrated a registry-based health system intervention improved CKD prevention and treatment.11 Additional studies are urgently needed. Racial inequities in kidney health and health care have not improved over decades and, in some cases, are worsening.12 If we are to make meaningful progress toward kidney health equity, serious efforts to eliminate factors that promote inequities from their inception, including those that emerge in the context of primary care, will be required.

Disclosures

L.E. Boulware reports serving as a scientific advisor for, or member of, the Association for Clinical and Translational Science, JAMA (on the editorial board), Journal of the American Medical Association Network Online (on the editorial board), and the Robert Wood Johnson Clinical Scholars National Advisory Committee; and receiving honoraria from Robert Wood Johnson Clinical Scholars Program and various universities for visiting professorships.

Funding

None.

Author Contributions

L.E. Boulware conceptualized the study, wrote the original draft, and reviewed and edited the manuscript.

Footnotes

  • Published online ahead of print. Publication date available at www.jasn.org.

  • Copyright © 2022 by the American Society of Nephrology

References

  1. ↵
    1. Bailey ZD,
    2. Krieger N,
    3. Agénor M,
    4. Graves J,
    5. Linos N,
    6. Bassett MT
    : Structural racism and health inequities in the USA: Evidence and interventions. Lancet 389: 1453–1463, 2017
    OpenUrlCrossRefPubMed
  2. ↵
    1. Gu A,
    2. Yue Y,
    3. Desai RP,
    4. Argulian E
    : Racial and ethnic differences in antihypertensive medication use and blood pressure control among US adults with hypertension: The National Health and Nutrition Examination Survey, 2003 to 2012. Circ Cardiovasc Qual Outcomes 10: e003166, 2017
    OpenUrlAbstract/FREE Full Text
  3. ↵
    1. Evans K,
    2. Coresh J,
    3. Bash LD,
    4. Gary-Webb T,
    5. Köttgen A,
    6. Carson K, et al
    : Race differences in access to health care and disparities in incident chronic kidney disease in the US. Nephrol Dial Transplant 26: 899–908, 2011
    OpenUrlCrossRefPubMed
  4. ↵
    1. Crews DC,
    2. Kuczmarski MF,
    3. Miller ER 3rd,
    4. Zonderman AB,
    5. Evans MK,
    6. Powe NR
    : Dietary habits, poverty, and chronic kidney disease in an urban population. J Ren Nutr 25: 103–110, 2015
    OpenUrlCrossRefPubMed
  5. ↵
    1. Kangovi S,
    2. Barg FK,
    3. Carter T,
    4. Long JA,
    5. Shannon R,
    6. Grande D
    : Understanding why patients of low socioeconomic status prefer hospitals over ambulatory care. Health Aff (Millwood) 32: 1196–1203, 2013
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Sperati CJ,
    2. Soman S,
    3. Agrawal V,
    4. Liu Y,
    5. Abdel-Kader K,
    6. Diamantidis CJ, et al; National Kidney Foundation Education Committee
    : Primary care physicians’ perceptions of barriers and facilitators to management of chronic kidney disease: A mixed methods study. PLoS One 14: e0221325, 2019
    OpenUrlPubMed
  7. ↵
    1. Murphy KA,
    2. Greer RC,
    3. Roter DL,
    4. Crews DC,
    5. Ephraim PL,
    6. Carson KA, et al
    : Awareness and discussions about chronic kidney disease among African-Americans with chronic kidney disease and hypertension: A mixed methods study. J Gen Intern Med 35: 298–306, 2020
    OpenUrlPubMed
  8. ↵
    1. Boulware LE,
    2. Carson KA,
    3. Troll MU,
    4. Powe NR,
    5. Cooper LA
    : Perceived susceptibility to chronic kidney disease among high-risk patients seen in primary care practices. J Gen Intern Med 24: 1123–1129, 2009
    OpenUrlCrossRefPubMed
  9. ↵
    1. Kahn LS,
    2. Vest BM,
    3. Madurai N,
    4. Singh R,
    5. York TR,
    6. Cipparone CW, et al
    : Chronic kidney disease (CKD) treatment burden among low-income primary care patients. Chronic Illn 11: 171–183, 2015
    OpenUrlCrossRefPubMed
  10. ↵
    1. Boulware LE,
    2. Ephraim PL,
    3. Hill-Briggs F,
    4. Roter DL,
    5. Bone LR,
    6. Wolff JL, et al
    : Hypertension self-management in socially disadvantaged African Americans: The Achieving Blood Pressure Control Together (ACT) randomized comparative effectiveness trial. J Gen Intern Med 35: 142–152, 2020
    OpenUrlPubMed
  11. ↵
    1. Tuot DS,
    2. McCulloch CE,
    3. Velasquez A,
    4. Schillinger D,
    5. Hsu CY,
    6. Handley M, et al
    : Impact of a primary care CKD registry in a US public safety-net health care delivery system: A pragmatic randomized trial. Am J Kidney Dis 72: 168–177, 2018
    OpenUrlCrossRefPubMed
  12. ↵
    1. Purnell TS,
    2. Bae S,
    3. Luo X,
    4. Johnson M,
    5. Crews DC,
    6. Cooper LA, et al
    : National trends in the association of race and ethnicity with predialysis nephrology care in the United States from 2005 to 2015. JAMA Netw Open 3: e2015003, 2020
    OpenUrlCrossRef
PreviousNext
Back to top

In this issue

Journal of the American Society of Nephrology: 33 (7)
Journal of the American Society of Nephrology
Vol. 33, Issue 7
July 2022
  • Table of Contents
  • Table of Contents (PDF)
  • About the Cover
  • Index by author
View Selected Citations (0)
Print
Download PDF
Sign up for Alerts
Email Article
Thank you for your help in sharing the high-quality science in JASN.
Enter multiple addresses on separate lines or separate them with commas.
Looking Upstream–The Role of Primary Care in Addressing US Race Inequities in Kidney Health
(Your Name) has sent you a message from American Society of Nephrology
(Your Name) thought you would like to see the American Society of Nephrology web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Looking Upstream–The Role of Primary Care in Addressing US Race Inequities in Kidney Health
L. Ebony Boulware
JASN Jul 2022, 33 (7) 1249-1251; DOI: 10.1681/ASN.2021101289

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Request Permissions
Share
Looking Upstream–The Role of Primary Care in Addressing US Race Inequities in Kidney Health
L. Ebony Boulware
JASN Jul 2022, 33 (7) 1249-1251; DOI: 10.1681/ASN.2021101289
del.icio.us logo Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like

Jump to section

  • Article
    • Disclosures
    • Funding
    • Author Contributions
    • Footnotes
    • References
  • Figures & Data Supps
  • Info & Metrics
  • View PDF

More in this TOC Section

Perspective

  • Health Care Equity and Justice Scorecard To Increase Diversity in Clinical Trial Recruitment and Retention
  • Acknowledging Socioecological Systems to Address the Systemic Racial Disparities in Children with Kidney Disease
Show more Perspective

Special Series on Addressing Racial and Ethnic Disparities in Kidney Disease

  • United States Renal Data System Spotlight on Racial and Ethnic Health Equity: Progress, but Much Remains to Discover, Understand, and Improve
  • Kidney Health Disparities: The Goal is Elimination
  • Navigating to Kidney Health Equity
Show more Special Series on Addressing Racial and Ethnic Disparities in Kidney Disease

Cited By...

  • No citing articles found.
  • Google Scholar

Similar Articles

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Keywords

  • health inequity
  • race
  • primary care
  • primary health care
  • racial and ethnic disparities

Articles

  • Current Issue
  • Early Access
  • Subject Collections
  • Article Archive
  • ASN Annual Meeting Abstracts

Information for Authors

  • Submit a Manuscript
  • Author Resources
  • Editorial Fellowship Program
  • ASN Journal Policies
  • Reuse/Reprint Policy

About

  • JASN
  • ASN
  • ASN Journals
  • ASN Kidney News

Journal Information

  • About JASN
  • JASN Email Alerts
  • JASN Key Impact Information
  • JASN Podcasts
  • JASN RSS Feeds
  • Editorial Board

More Information

  • Advertise
  • ASN Podcasts
  • ASN Publications
  • Become an ASN Member
  • Feedback
  • Follow on Twitter
  • Password/Email Address Changes
  • Subscribe to ASN Journals
  • Wolters Kluwer Partnership

© 2022 American Society of Nephrology

Print ISSN - 1046-6673 Online ISSN - 1533-3450

Powered by HighWire