Q&A: Uncovering Sex Differences in the Management of Chronic Kidney Disease
Up to 37 million Americans are affected by chronic kidney disease (CKD), a loss of kidney function over time, with a higher prevalence of the disease among females than males (15.4 percent vs. 12.6 percent). Treatments for the disease are focused on slowing the progression of kidney damage to prevent it from manifesting into end-stage kidney failure. Corresponding author, Jorge A. Rodriguez, MD, and senior author, Lipika Samal, MD, MPH, both of Division of General Internal Medicine and Primary Care, examined how primary care treatment for CKD differed among males and females. The findings from the study are published in JAMA.
Lipika Samal
Jorge Rodriguez
Q: Can you describe the methods of your study and share the primary findings?
JR: Using electronic health record (EHR) data from 15 primary care practices affiliated with the Brigham, we analyzed how the primary care management of CKD differed among male and female patients. We used EHR data from 7,903 patients and analyzed how treatments aligned with the guidelines of CKD management in primary care. We then compared treatments for males and females.
LS: After our analysis, we found females with CKD were more likely to receive worse care than males overall. When compared to males, females were less likely to be sent to the laboratory for essential testing and monitoring and less likely to be prescribed medications to lower the risk of kidney failure, such as renin-angiotensin system inhibitors. Females were also found to be less likely to meet recommended blood pressure goals, which can increase their risk of cardiovascular events and end-stage kidney disease. In addition, females were less likely to be referred to see a nephrologist, or kidney specialist. These results were surprising to us, but they highlight an opportunity for solutions and strategies to fill these gaps in care.
Q: Knowing that females are more affected by CKD than males, why is there a gap in treatment?
JR: The exact reason why there is a difference in the management of treatment is unclear. I think there may be a few things at play here. There may be a component of bias and unconscious bias as it relates to sex. Also, there may be a component of the patient’s and the physician’s level of awareness of CKD and how it’s different from hypertension and diabetes.
Q: What can physicians and patients do to fill the gaps to make CKD treatment more equitable?
JR: There’s an opportunity for physicians to take a step back and reflect on unconscious bias in their practice to make sure it doesn’t continue when they meet with patients. I also think primary care physicians can take advantage of implementing clinical decision supports to help realign them with guideline-based care, like some of the work Dr. Samal has done.
LS: I think increasing the patient’s awareness of CKD and educating them also can help fill these gaps. Nurses and team-based care can facilitate the patient education to improve the patient’s understanding of the disease and available treatment options, which can empower them to become closely engaged in their treatment plan. Also, population health managers can play a role. They, for example, can help find patients who are due for necessary labs, prepare the lab order in Epic for the primary care provider to sign off on and contact the patient to invite them in for lab work. This would ensure these patients don’t fall through the cracks.
Q: What is Mass General Brigham doing or should be doing to address the disparities in CKD?
LS: From a primary care standpoint, we have access to electronic consultations, where a PCP can send a specific question to a kidney specialist. I’ve found when patients are comfortable talking to their care team, they’ll also send us questions electronically, so the care extends outside the clinical setting. There are opportunities to improve patient education in this area as well, which can be facilitated through Patient Gateway. I’ve also directed patients and physicians to the National Kidney Foundation for relevant resources. Engaging patients throughout the treatment process, but also educating them, is essential.