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Race and End-Stage Renal Disease: Socioeconomic Status and Access to Health Care as Mediating Factors

Race and End-Stage Renal Disease: Socioeconomic Status and Access to Health Care as Mediating... Abstract Objective: To examine whether lower socioeconomic status and limited access to health care explain the racial inequities in the incidence of end-stage renal disease (ESRD), and whether these factors are independently associated with ESRD. Methods: This case-control study compared 716 patients with ESRD with 361 population controls of the same age, 20 to 64 years old, from Maryland, Virginia, West Virginia, and Washington, DC. Race, indicators of socioeconomic status (household annual income, years of education), and indicators of access to health care (health insurance status, number of missing teeth, usual source of care, use of preventive services) were assessed via a telephone interview. Results: Independent risk factors for ESRD included non-white race (odds ratio for blacks, 5.5; 95% confidence interval, 3.8 to 8.0; odds ratio for other nonwhites, 3.5; 95% confidence interval, 1.2 to 10.0), categories of income (odds ratio gradient, 1.0 to 4.5; 95% confidence interval, 2.6 to 7.8), receipt of Medicaid benefits (odds ratio, 3.5; 95% confidence interval, 1.5 to 8.4), and number of missing teeth (odds ratio gradient, 1.0 to 2.2; 95% confidence interval, 1.2 to 4.1). Adjustment for socioeconomic variables reduced the odds ratio for blacks only partially, from 8.1 to 5.5. The proportions of ESRD incidence that could be attributed to each risk factor were 46% for minority race, 53% for income categories, and 33% for missing teeth. Conclusions: Low socioeconomic status and limited access to health care were strong risk factors for kidney failure, but they explained only part of the excess of ESRD in blacks. Racial and social factors account for a large part of ESRD incidence. The mechanisms of these associations should be targeted by further research.(Arch Intern Med. 1995;155:1201-1208) References 1. US Renal Data System. USRDS Annual Data Report . Bethesda, Md: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 1993. 2. McClellan W, Tuttle E, Issa A. Racial differences in the incidence of end-stage hypertensive renal disease are not entirely explained by differences in the prevalence of hypertension. Am J Kidney Dis . 1988;12:285-290.Crossref 3. Cowie CC, Port FK, Wolfe RA, Savage PJ, Moll PP, Hawthorne PM. Disparities in incidence of diabetic end-stage renal disease according to race and type of diabetes. N Engl J Med . 1989;321:1074-1079.Crossref 4. Dustan HP, Curtis JJ, Luke RG, Rostand SG. Systemic hypertension and the kidney in African American patients. Am J Cardiol . 1987;60:731-771. 5. Levy SB, Talner LB, Coel MN, Holle R, Stone RA. Renal vasculature in essential hypertension: racial differences. Ann Intern Med . 1978;88:12-16.Crossref 6. Lilley JL, Hsu L, Stone RA. Racial disparity in plasma volume in hypertensive man. Ann Intern Med . 1976;84:707-708.Crossref 7. Aviv A, Gardner J. Racial differences in ion regulation and their possible links to hypertension in African Americans. Hypertension . 1989;14:584-589.Crossref 8. James GD, Sealey JE, Mueller F, Alderman M, Madhavan S, Laragh JH. Renin relationship to sex, race and age in a normotensive population. J Hypertens . 1986;4( (suppl 5) ):S387-S389.Crossref 9. Levy SB, Lilley JJ, Frigon RP, Stone RA. Urinary kallikrein and plasma renin activity as determinants of renal blood flow: the influence of race and sodium intake. J Clin Invest . 1977;60:129-138.Crossref 10. Freedman BI, Espeland MA, Heise ER, Adams P, Buckalew VM, Canzanello VJ. Racial differences in HLA antigen frequency and hypertensive renal failure. Am J Hypertens . 1991;4:393-398.Crossref 11. Dustan HP. Growth factors and racial differences in severity of hypertension and renal disease. Lancet . 1992;339:1339-1340.Crossref 12. Navarro V. Race or class versus race and class: mortality differentials in the United States. Lancet . 1990;336:1238-1240.Crossref 13. Pincus T, Callahan LF, Burkhauser RV. Most chronic diseases are reported more frequently by individuals with fewer than 12 years of formal education in the age 18-64 United States population. J Chronic Dis . 1987;40:865-874.Crossref 14. Whittle JC, Whelton PK, Seidler AJ, Klag MJ. Does racial variation in risk factors explain African American—white differences in the incidence of hypertensive end-stage renal disease? Arch Intern Med . 1991;151:1359-1364.Crossref 15. Brancati FL, Whittle JC, Whelton PK, Seidler AJ, Klag MJ. The excess incidence of diabetic end-stage renal disease among African Americans. JAMA . 1992;268:3079-3084.Crossref 16. Rostand SG, Brown G, Kirk KA, Rutsky EA, Dustan HP. Renal insufficiency in treated essential hypertension. N Engl J Med . 1989;320:684-688.Crossref 17. Byrne C, Nedelman J, Luke RG. Race, socioeconomic status, and the development of end-stage renal disease. Am J Kidney Dis . 1994;23:16-22.Crossref 18. Young EW, Mauger EA, Jiang KH, Port FK, Wolfe RA. Socioeconomic status and end-stage renal disease in the United States. Kidney Int . 1994;45:907-911.Crossref 19. Hayward RA, Shapiro MF, Freeman HE, Corey CR. Inequities in health services among insured Americans. N Engl J Med . 1988;318:1507-1512.Crossref 20. Blendon RJ, Aiken LH, Freeman HE, Corey CR. Access to medical care for African American and white Americans. JAMA . 1989;261:278-281.Crossref 21. Burstin HR, Lipsitz SR, Brennan TA. Socioeconomic status and risk for substandard medical care. JAMA . 1992;268:2383-2387.Crossref 22. Weissman JS, Stern R, Fielding SL, Epstein AM. Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med . 1991;114:325-331.Crossref 23. Brook RH, Ware JE, Rogers WH, et al. Does free care improve adults' health? results from a randomized controlled trial. N Engl J Med . 1983;309:1426-1434.Crossref 24. Lurie N, Ward NB, Shapiro MF, Brook RH. Termination from Medi-Cal: does it affect health? N Engl J Med . 1984;311:480-484.Crossref 25. Council on Ethical and Judicial Affairs. African American—white disparities in health care. JAMA . 1990;263:2344-2346.Crossref 26. Perneger TV, Myers TL, Klag MJ, Whelton PK. Effectiveness of the Waksberg telephone sampling method for the selection of population controls. Am J Epidemiol . 1993;138:574-584. 27. Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res . 1974;9:208-220. 28. Hosmer DW, Lemeshow S. Applied Logistic Regression . New York, NY: John Wiley & Sons Inc; 1989. 29. Bruzzi P, Green SB, Byar DP, Brinton LA, Schairer C. Estimating the population attributable risk for multiple risk factors using case-control data. Am J Epidemiol . 1985;122:904-914. 30. Schlesselman JJ. Case-Control Studies: Design, Conduct, Analysis . New York, NY: Oxford University Press; 1982. 31. Wilkinson L. SYSTAT: The System for Statistics . Evanston, Ill: SYSTAT Inc; 1990. 32. Easterling RE. Racial factors in the incidence and causation of end-stage renal disease (ESRD). Trans Am Soc Artif Intern Organs . 1977;23:28-32.Crossref 33. Rostand SG, Kirk KA, Rutsky EA, Pate BA. Racial differences in the incidence of end stage renal disease. N Engl J Med . 1982;306:1276-1279.Crossref 34. Ferguson R, Grim CE, Opgenroth TJ. The epidemiology of end-stage renal disease: the six-year South-Central Los Angeles experience, 1980-1985. Am J Public Health . 1987;77:864-865.Crossref 35. Sorlie P, Rogot E, Anderson R, Johnson NJ, Backlund E. Black-white mortality differences by family income. Lancet . 1992;340:346-350.Crossref 36. Cooper R. A note on the biologic concept of race and its application in epidemiologic research. Am Heart J . 1984;108:715-723.Crossref 37. Jones CP, La Veist TA, Lillie-Blanton M. 'Race' in the epidemiologic literature: an examination of the American Journal of Epidemiology, 1921-1990. Am J Epidemiol . 1991;134:1079-1084. 38. Klag MJ, Whelton PK, Coresh J, Grim CE, Kuller LH. The association of skin color with blood pressure in US African Americans with low socioeconomic status. JAMA . 1991;265:599-602.Crossref 39. Marmot MG, Shipley MJ, Rose G. Inequalities in death: specific explanations of a general pattern? Lancet . 1984;1:1003-1006.Crossref 40. Adler NE, Boyce WT, Chesney MA, Folkman S, Syme L. Socioeconomic inequalities in health: no easy solution. JAMA . 1993;269:3140-3145.Crossref 41. Hurowitz JC. Toward a social policy for health. N Engl J Med . 1993;329:130-133.Crossref 42. Davis K, Gold M, Makuc D. Access to health care for the poor: does the gap remain? Annu Rev Public Health . 1981;2:159-182.Crossref 43. Palmqvist S, Söderfeldt B, Arnbjerg D. Self-assessment of dental conditions: validity of a questionnaire. Community Dent Oral Epidemiol . 1991;19:249-251.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Race and End-Stage Renal Disease: Socioeconomic Status and Access to Health Care as Mediating Factors

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Publisher
American Medical Association
Copyright
Copyright © 1995 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1995.00430110121013
Publisher site
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Abstract

Abstract Objective: To examine whether lower socioeconomic status and limited access to health care explain the racial inequities in the incidence of end-stage renal disease (ESRD), and whether these factors are independently associated with ESRD. Methods: This case-control study compared 716 patients with ESRD with 361 population controls of the same age, 20 to 64 years old, from Maryland, Virginia, West Virginia, and Washington, DC. Race, indicators of socioeconomic status (household annual income, years of education), and indicators of access to health care (health insurance status, number of missing teeth, usual source of care, use of preventive services) were assessed via a telephone interview. Results: Independent risk factors for ESRD included non-white race (odds ratio for blacks, 5.5; 95% confidence interval, 3.8 to 8.0; odds ratio for other nonwhites, 3.5; 95% confidence interval, 1.2 to 10.0), categories of income (odds ratio gradient, 1.0 to 4.5; 95% confidence interval, 2.6 to 7.8), receipt of Medicaid benefits (odds ratio, 3.5; 95% confidence interval, 1.5 to 8.4), and number of missing teeth (odds ratio gradient, 1.0 to 2.2; 95% confidence interval, 1.2 to 4.1). Adjustment for socioeconomic variables reduced the odds ratio for blacks only partially, from 8.1 to 5.5. The proportions of ESRD incidence that could be attributed to each risk factor were 46% for minority race, 53% for income categories, and 33% for missing teeth. Conclusions: Low socioeconomic status and limited access to health care were strong risk factors for kidney failure, but they explained only part of the excess of ESRD in blacks. Racial and social factors account for a large part of ESRD incidence. The mechanisms of these associations should be targeted by further research.(Arch Intern Med. 1995;155:1201-1208) References 1. US Renal Data System. USRDS Annual Data Report . Bethesda, Md: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 1993. 2. McClellan W, Tuttle E, Issa A. Racial differences in the incidence of end-stage hypertensive renal disease are not entirely explained by differences in the prevalence of hypertension. Am J Kidney Dis . 1988;12:285-290.Crossref 3. Cowie CC, Port FK, Wolfe RA, Savage PJ, Moll PP, Hawthorne PM. Disparities in incidence of diabetic end-stage renal disease according to race and type of diabetes. N Engl J Med . 1989;321:1074-1079.Crossref 4. Dustan HP, Curtis JJ, Luke RG, Rostand SG. Systemic hypertension and the kidney in African American patients. Am J Cardiol . 1987;60:731-771. 5. Levy SB, Talner LB, Coel MN, Holle R, Stone RA. Renal vasculature in essential hypertension: racial differences. Ann Intern Med . 1978;88:12-16.Crossref 6. Lilley JL, Hsu L, Stone RA. Racial disparity in plasma volume in hypertensive man. Ann Intern Med . 1976;84:707-708.Crossref 7. Aviv A, Gardner J. Racial differences in ion regulation and their possible links to hypertension in African Americans. Hypertension . 1989;14:584-589.Crossref 8. James GD, Sealey JE, Mueller F, Alderman M, Madhavan S, Laragh JH. Renin relationship to sex, race and age in a normotensive population. J Hypertens . 1986;4( (suppl 5) ):S387-S389.Crossref 9. Levy SB, Lilley JJ, Frigon RP, Stone RA. Urinary kallikrein and plasma renin activity as determinants of renal blood flow: the influence of race and sodium intake. J Clin Invest . 1977;60:129-138.Crossref 10. Freedman BI, Espeland MA, Heise ER, Adams P, Buckalew VM, Canzanello VJ. Racial differences in HLA antigen frequency and hypertensive renal failure. Am J Hypertens . 1991;4:393-398.Crossref 11. Dustan HP. Growth factors and racial differences in severity of hypertension and renal disease. Lancet . 1992;339:1339-1340.Crossref 12. Navarro V. Race or class versus race and class: mortality differentials in the United States. Lancet . 1990;336:1238-1240.Crossref 13. Pincus T, Callahan LF, Burkhauser RV. Most chronic diseases are reported more frequently by individuals with fewer than 12 years of formal education in the age 18-64 United States population. J Chronic Dis . 1987;40:865-874.Crossref 14. Whittle JC, Whelton PK, Seidler AJ, Klag MJ. Does racial variation in risk factors explain African American—white differences in the incidence of hypertensive end-stage renal disease? Arch Intern Med . 1991;151:1359-1364.Crossref 15. Brancati FL, Whittle JC, Whelton PK, Seidler AJ, Klag MJ. The excess incidence of diabetic end-stage renal disease among African Americans. JAMA . 1992;268:3079-3084.Crossref 16. Rostand SG, Brown G, Kirk KA, Rutsky EA, Dustan HP. Renal insufficiency in treated essential hypertension. N Engl J Med . 1989;320:684-688.Crossref 17. Byrne C, Nedelman J, Luke RG. Race, socioeconomic status, and the development of end-stage renal disease. Am J Kidney Dis . 1994;23:16-22.Crossref 18. Young EW, Mauger EA, Jiang KH, Port FK, Wolfe RA. Socioeconomic status and end-stage renal disease in the United States. Kidney Int . 1994;45:907-911.Crossref 19. Hayward RA, Shapiro MF, Freeman HE, Corey CR. Inequities in health services among insured Americans. N Engl J Med . 1988;318:1507-1512.Crossref 20. Blendon RJ, Aiken LH, Freeman HE, Corey CR. Access to medical care for African American and white Americans. JAMA . 1989;261:278-281.Crossref 21. Burstin HR, Lipsitz SR, Brennan TA. Socioeconomic status and risk for substandard medical care. JAMA . 1992;268:2383-2387.Crossref 22. Weissman JS, Stern R, Fielding SL, Epstein AM. Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med . 1991;114:325-331.Crossref 23. Brook RH, Ware JE, Rogers WH, et al. Does free care improve adults' health? results from a randomized controlled trial. N Engl J Med . 1983;309:1426-1434.Crossref 24. Lurie N, Ward NB, Shapiro MF, Brook RH. Termination from Medi-Cal: does it affect health? N Engl J Med . 1984;311:480-484.Crossref 25. Council on Ethical and Judicial Affairs. African American—white disparities in health care. JAMA . 1990;263:2344-2346.Crossref 26. Perneger TV, Myers TL, Klag MJ, Whelton PK. Effectiveness of the Waksberg telephone sampling method for the selection of population controls. Am J Epidemiol . 1993;138:574-584. 27. Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res . 1974;9:208-220. 28. Hosmer DW, Lemeshow S. Applied Logistic Regression . New York, NY: John Wiley & Sons Inc; 1989. 29. Bruzzi P, Green SB, Byar DP, Brinton LA, Schairer C. Estimating the population attributable risk for multiple risk factors using case-control data. Am J Epidemiol . 1985;122:904-914. 30. Schlesselman JJ. Case-Control Studies: Design, Conduct, Analysis . New York, NY: Oxford University Press; 1982. 31. Wilkinson L. SYSTAT: The System for Statistics . Evanston, Ill: SYSTAT Inc; 1990. 32. Easterling RE. Racial factors in the incidence and causation of end-stage renal disease (ESRD). Trans Am Soc Artif Intern Organs . 1977;23:28-32.Crossref 33. Rostand SG, Kirk KA, Rutsky EA, Pate BA. Racial differences in the incidence of end stage renal disease. N Engl J Med . 1982;306:1276-1279.Crossref 34. Ferguson R, Grim CE, Opgenroth TJ. The epidemiology of end-stage renal disease: the six-year South-Central Los Angeles experience, 1980-1985. Am J Public Health . 1987;77:864-865.Crossref 35. Sorlie P, Rogot E, Anderson R, Johnson NJ, Backlund E. Black-white mortality differences by family income. Lancet . 1992;340:346-350.Crossref 36. Cooper R. A note on the biologic concept of race and its application in epidemiologic research. Am Heart J . 1984;108:715-723.Crossref 37. Jones CP, La Veist TA, Lillie-Blanton M. 'Race' in the epidemiologic literature: an examination of the American Journal of Epidemiology, 1921-1990. Am J Epidemiol . 1991;134:1079-1084. 38. Klag MJ, Whelton PK, Coresh J, Grim CE, Kuller LH. The association of skin color with blood pressure in US African Americans with low socioeconomic status. JAMA . 1991;265:599-602.Crossref 39. Marmot MG, Shipley MJ, Rose G. Inequalities in death: specific explanations of a general pattern? Lancet . 1984;1:1003-1006.Crossref 40. Adler NE, Boyce WT, Chesney MA, Folkman S, Syme L. Socioeconomic inequalities in health: no easy solution. JAMA . 1993;269:3140-3145.Crossref 41. Hurowitz JC. Toward a social policy for health. N Engl J Med . 1993;329:130-133.Crossref 42. Davis K, Gold M, Makuc D. Access to health care for the poor: does the gap remain? Annu Rev Public Health . 1981;2:159-182.Crossref 43. Palmqvist S, Söderfeldt B, Arnbjerg D. Self-assessment of dental conditions: validity of a questionnaire. Community Dent Oral Epidemiol . 1991;19:249-251.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jun 12, 1995

References