October 2022 Healthy Intersections Podcast

Happy October, listeners. Here in Los Angeles, we are enjoying some cooler nighttime temperatures, and they are a welcome relief!

For this segment of the Healthy Intersections Podcast for October, I’d like to discuss a paper that Samy mentioned that was published in the October issue of Medical Care. The paper is called “The Role of Social Risk Factors in Dialysis Quality and Patient Outcomes Under a Medicare Quality Incentive Program“. Since I do a lot of research on social risk adjustment and have studied end-stage renal disease, or ESRD, and dialysis in the past, I was really interested to learn more.

The authors, led by Andrew Breck of Insight Policy Research under a CMS evaluation contract, have described their efforts to understand the role of four “social risk factors” on outcomes among dialysis patients. Specifically, they were looking at the Medicare Quality Improvement Program, or QIP, for ESRD. This pay-for-quality program aligns Medicare reimbursements to dialysis facilities with their performance on ESRD-related quality measures, such as dialysis adequacy and use of fistulas.

In the past, researchers have noted disparities in dialysis quality by race, ethnicity, dual enrollment in Medicare and Medicaid (which is a marker of poverty), and residing in a rural area. The authors sought to understand whether these disparities in quality of care have improved or worsened under the QIP. They also wanted to know whether there were variations in QIP payment reductions based on these four factors.

So before I go further with describing their findings, I wanted to talk about the use of race and ethnicity as so-called “social risk factors.” While it is true that there are documented differences in dialysis quality and outcomes for Black and Hispanic people with ESRD relative to White people, that doesn’t mean that being Black or Hispanic is a “social risk factor.” Instead, I would argue that the risks arise, at least in part, from unequal treatment of Black and Hispanic people in the healthcare system, the educational system, not to mention the financial system (and plenty of other systems, too). So while I agree with the idea of looking at different populations to understand various risk profiles, to my mind, it’s not right to identify race and ethnicity as the risk factors. Instead, it’s racism and bias that are the true risk factors – both interpersonal and structural racism. When we are doing work to advance health equity, I feel it is very important to understand what it is we are studying and what the true risk factors are. Especially since race and ethnicity are not modifiable, but unequal treatment can absolutely be eradicated!

This said, the authors show that Black and Hispanic people were less likely to have seen a nephrologist prior to beginning dialysis. In fact, fewer than half of the Black, Hispanic, and dual enrollees had received nephrologist care before dialysis. This is truly abysmal. Consider than if you get to the point of having ESRD and needing dialysis, it does not happen overnight. This is a real gap in care for people with diabetes and/or hypertension at risk of ESRD.

After adjusting for covariates, the authors found that facilities with a higher percentage of Black patients and dual enrollees scored worse on most clinical measures, and Black patients fared worse than White patients on two out of three outcomes. In contrast, facilities with more Hispanic patients and rural facilities generally scored better, and Hispanic patients fared better than White patients on two out of three outcomes. This is an interesting finding that deserves further study.

My last comment on this article has to do with the abstract’s conclusions. The authors state “There is no evidence of widening disparities in dialysis care or patient outcomes across patient groups under the ESRD QIP.” This is true, but it’s not the whole story — in the body of the paper, they state that they found persistent disparities. So… the disparities are there, but at least they aren’t getting worse? Talk about a positive spin!

That’s all for today. Thank you for listening. Please visit TheMedicalCareBlog.com for a transcript of this month’s episode, as well as a place to leave your feedback.

We hope you’ve enjoyed the October podcast from your favorite academic healthcare blog!