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Published ahead of print on November 9, 2005
Clin J Am Soc Nephrol 1: 58-63, 2006
© 2006 American Society of Nephrology
doi: 10.2215/CJN.00560705
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Quality of Care among Aboriginal Hemodialysis Patients

Sophia H. Chou*, Marcello Tonelli{dagger},{ddagger},§, John S. Bradley{ddagger}, Sita Gourishankar{ddagger}, Brenda R. Hemmelgarn*,||; for the Alberta Kidney Disease Network

* Department of Medicine, Division of Nephrology, and || Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; and {dagger} Institute of Health Economics, and {ddagger} Department of Medicine, Division of Nephrology, and § Division of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada

Address correspondence to: Dr. Brenda Hemmelgarn, Division of Nephrology, Foothills Medical Center, 1403 29th Street NW, Calgary, Alberta, Canada T2N 2T9. Phone: 403-944-2745; Fax: 403-944-2876; E-mail: brenda.hemmelgarn{at}calgaryhealthregion.ca


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Registry data report racial differences in hemodialysis (HD) care, with ethnic minorities at a disadvantage. However, little information is available regarding Aboriginal HD patients specifically. This study sought to compare the quality of HD care between Aboriginal and non-Aboriginal patients in Canada. All adults who were established on HD for ≥6 mo in a single Canadian province were included. Clinical information was obtained by patient interview and chart review, with race determined by self-report. Quality of HD care was assessed by small solute clearance, BP control, mineral metabolism, and anemia management. Of the 835 patients, 95 (11.4%) were Aboriginal. Aboriginal patients were significantly younger, were more likely to have diabetes as the cause of ESRD, and had a higher degree of comorbidity than non-Aboriginal patients. There were no differences between Aboriginal and non-Aboriginal patients for small solute clearance, anemia management, or use of permanent vascular access. Aboriginal patients, however, were less likely to achieve a target predialysis systolic BP of <140 mmHg (29.5 versus 44.9%; P = 0.004), a target phosphate level of <1.8 mmol/L (40.0 versus 67.3%; P < 0.0001), and a calcium-phosphate product <4.4 mmol2/L2 (52.6 versus 72.7%; P < 0.001). Quality of care was found to be similar for Aboriginal compared with non-Aboriginal HD patients except for differences in predialysis systolic BP and mineral metabolism, which may be influenced by individual and cultural factors. Explanations for these differences and their impact on morbidity and mortality warrant further investigation.


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
In the past two decades, there has been a continuous increase in ESRD worldwide (1). Native Americans in particular seem to be at high risk for developing ESRD, with prevalence rates three times that for white individuals (3540 versus 1004 per million population) (1). Aboriginal people in Canada are also at high risk, with an eight-fold increase in ESRD between 1980 and 2000 (2). The high prevalence of diabetes and its complications are likely contributing to the high rates of ESRD among Aboriginal patients (3–5), although other factors, including lower socioeconomic status (6,7) and reduced access to primary care (8), have also been implicated.

Inequity in health outcomes for Aboriginal people have been demonstrated in a variety of conditions, including cardiovascular disease, trauma, and musculoskeletal syndromes (9–12). Although recent evidence suggests racial disparity in hemodialysis (HD) adequacy and outcomes in the North American ESRD population, most studies have focused on the African, Hispanic, and Asian ethnic groups and have not included the Aboriginal population (13–18). One of the few studies that did focus on adequacy of HD care for Aboriginal patients suggests equivalent or better dialytic care compared with black or white patients (19). Race in this study, however, was classified by facility staff, with potential for misclassification. Identification of potential difference in HD care for Aboriginal patients would enable targeted provision of care for a population that is already at increased risk for adverse health outcomes. We sought to compare the quality of HD care between Aboriginal and non-Aboriginal patients in this multicenter observational study.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Study Population
We used a cross-sectional study design to establish a cohort of HD patients in the province of Alberta, Canada. ESRD care in Alberta is coordinated through two renal programs, the Northern Alberta Renal Program and the Southern Alberta Renal Program. Both the Northern Alberta Renal Program and the Southern Alberta Renal Program maintain an up-to-date computerized list of HD patients within their program, which was used to identify study participants. Eligible patients included those who were 18 yr and older and had been established on regular in-center HD for ≥6 mo before being interviewed. Patients who were on self-care modalities, including peritoneal dialysis, home HD, and nocturnal HD, were not included.

Data Collection
In the spring of 2004, all consenting in-center HD patients were interviewed by a physician during their HD treatment session. Data were collected on demographic and clinical characteristics, including gender, age, cause of ESRD, number of years on HD, type of vascular access currently being used (arteriovenous graft, arteriovenous fistula, or central venous catheter), weekly erythropoietin dose, predialysis BP (mean sitting systolic and diastolic BP from the three previous hemodialysis sessions), and use of antihypertensive agents. Information on comorbidities was also abstracted from the medical records to derive the Charlson Comorbidity Score (20). This score has been validated in the HD population (21).

Laboratory parameters based on the mean values over a 3-mo period before the interview were also obtained. These parameters included serum hemoglobin, albumin, calcium, phosphate, parathyroid hormone (PTH), ferritin, transferrin saturation, and small solute clearance (Kt/V). These parameters were used to assess dialysis adequacy, based on the guidelines published in the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) guidelines (22–24).

Classification of Patient Race
Information on race was collected by patient self-report during the interview. Patients were asked with which racial group they most identified themselves, which then was categorized into white, Aboriginal, East Asian, South Asian, Middle Eastern, black, Polynesian, mixed non-Aboriginal, and unknown. Because the focus of this study was on individuals of Aboriginal race and given the small number of patients in the other racial groups, we dichotomized race into Aboriginal and non-Aboriginal for the primary analysis. Patients of mixed race were included in the non-Aboriginal group. In a sensitivity analysis, Aboriginal and white patients were compared after exclusion of patients of all other races.

Statistical Analyses
We summarized baseline descriptive data in terms of percentages for categorical variables and means with SD for continuous variables. Group differences were compared with the {chi}2 test for categorical variables and t test for continuous variables. Quality of HD care for Aboriginal compared with non-Aboriginal patients, the primary study objective, was assessed through measures of BP control, anemia management (hemoglobin and iron indices as well as erythropoietin dose), control of mineral metabolism (calcium, phosphate, and PTH levels), and Kt/V. All statistical analyses were performed with SAS software version 8.2 (Cary, NC). P < 0.05 for differences between the racial groups was considered to be statistically significant. The study was approved by the Health Research Ethics Boards of the Universities of Calgary and Alberta.


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
A total of 877 HD patients in the province of Alberta were eligible for inclusion, 42 (5%) of whom declined to participate. Of the 835 study participants, 95 (11.4%) were Aboriginal, 591 (70.8%) were white, and 149 (17.8%) were non-Aboriginal nonwhite. Compared with non-Aboriginal HD patients, Aboriginal HD patients were significantly younger (53.5 versus 64.7 yr; P < 0.001), had a higher postdialysis body mass index (27.7 versus 25.6; P = 0.004), had diabetes as their primary cause of ESRD (60.0 versus 33.7%; P < 0.0001), and had a higher degree of comorbidity as reflected by a higher Charlson Comorbidity Score (5.8 versus 5.1; P = 0.01) (Table 1). The duration on HD was similar between Aboriginal and non-Aboriginal patients (3.3 versus 3.4 yr; P = 0.66).


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  		Table 1. Baseline demographic and clinical characteristics of study participants, by racea

 
Measures of Quality of HD Care
BP Control.  Aboriginal HD patients had higher predialysis systolic (145.8 versus 142.8 mmHg; P = 0.18) and diastolic (78.7 versus 75.3 mmHg; P = 0.02) BP compared with non-Aboriginal HD patients (Table 2). When adequate BP control was defined as systolic BP <140 mmHg, Aboriginal HD patients were significantly less likely than non-Aboriginal HD patients to achieve this target (29.5 versus 44.9%; P = 0.004), despite using the same mean number of antihypertensive agents (1.4 versus 1.4; P = 0.95).


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  		Table 2. Measures of HD adequacy and BP control, by racea

 
Small Solute Clearance.  There was no difference in small solute clearance, expressed as mean Kt/V, (1.6 versus 1.6; P = 0.66) for Aboriginal patients compared with non-Aboriginal HD patients, even after stratifying by postdialysis body mass index (Table 2). Similarly, the percentage of patients who achieved a mean Kt/V >1.2, the NKF-K/DOQI recommended threshold for adequate hemodialysis dose (25), was similar between the two groups (96.8 versus 96.1%; P = 0.72).

Vascular Access.  NKF-K/DOQI guidelines recommend that at least 40% of prevalent HD patients maintain an arteriovenous fistula as their vascular access (23), with both Aboriginal and non-Aboriginal patients achieving this target. Use of a central venous catheter was the second most frequent form of vascular access for Aboriginal and non-Aboriginal patients (37.2 versus 31.9%). There was no statistically significant difference in the types of vascular access used for Aboriginal compared with non-Aboriginal HD patients (P = 0.51).

Mineral Metabolism.  When mineral metabolism was assessed as a measure of HD care, there were significant differences between Aboriginal and non-Aboriginal HD patients (Table 3). Compared with non-Aboriginal patients, Aboriginal patients were significantly less likely to achieve a recommended target phosphate of <1.8 mmol/L (67.3 versus 40.0%; P < 0.0001) and a calcium-phosphate product of <4.4 mmol2/L2 (72.7 versus 52.6%; P < 0.001). When patients were stratified further by duration on hemodialysis (≤1 yr versus >1 yr), a surrogate marker for residual renal function, Aboriginal patients persistently had worse mineral metabolism control compared with non-Aboriginal patients. Serum PTH and albumin levels were similar between Aboriginal and non-Aboriginal HD patients.


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  		Table 3. Anemia management and mineral metabolism, by race

 
Anemia Management.  Nonsignificant differences in anemia management were evident between Aboriginal and non-Aboriginal HD patients (Table 3), with Aboriginal patients less likely to achieve a target hemoglobin >110 g/L (66.3 versus 72.3%; P = 0.22), despite having increased erythropoietin requirements (Table 4). Aboriginal and non-Aboriginal HD patients had similar hemoglobin levels (115.9 versus 116.7 g/L; P = 0.54) and transferrin saturation levels (34.9 versus 34.5%; P = 0.81). Results were unchanged in a subgroup analysis that was restricted to patients who were iron replete (defined as transferrin saturation >20%). All results were similar when Aboriginal and white participants were compared after exclusion of individuals of non-Aboriginal, nonwhite race (data not shown).


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  		Table 4. Erythropoietin requirements, by race

 

   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
In this large, population based study of HD patients, quality of care was similar between Aboriginal and non-Aboriginal patients for small solute clearance, anemia management, and use of a permanent access. Compared with non-Aboriginal HD patients, Aboriginal patients were significantly less likely to achieve target levels for predialysis systolic BP control and mineral metabolism. Although not statistically significant, Aboriginal HD patients also had higher erythropoietin requirements to achieve target hemoglobin levels.

Our results are similar to those of Frankenfield et al. (19), who also reported no difference in small solute clearance, use of permanent vascular access, and achieved hemoglobin and transferrin saturation targets for Aboriginal compared with white HD patients. However, in contrast to Frankenfield, we found a trend toward increasing erythropoietin requirement for Aboriginal compared with non-Aboriginal HD patients. This finding was independent of transferrin saturation, one of the most widely used and reliable indicators of iron status. The reason for the potential higher erythropoietin requirements among Aboriginal HD patients is unclear. Previous studies have suggested multiple mechanisms for differential erythropoietin responsiveness in dialysis populations, including female gender, inadequate dialysis dose, presence of diabetes, and inherited biologic differences (26–28). In a subanalysis stratified by gender and diabetes, we did not find a significant difference in erythropoietin dose requirements for Aboriginal HD patients, although this analysis was limited by the small number of patients. Other potential explanations for the apparent increased erythropoietin requirements among Aboriginal HD patients, such as a higher prevalence of infectious diseases and higher C-reactive protein levels, could not be assessed in this study.

Although not included in the study by Frankenfield et al. (19), we found significant differences in mineral metabolism between Aboriginal and non-Aboriginal HD patients, with Aboriginal patients less likely to achieve target serum phosphate and calcium-phosphate product levels. This finding persisted even after patients were stratified by time on hemodialysis, a surrogate marker for residual renal function. The reason for inadequate control of mineral metabolism is unclear but may be explained partly by differences in diet, with the Aboriginal diet composed of higher phosphate-containing foods. Patient compliance, socioeconomic status, and pharmacologic treatment of hyperphosphatemia are other possible contributing factors that may influence control of mineral metabolism and were not assessed in this study.

We also found that Aboriginal HD patients were significantly less likely to achieve a target predialysis systolic BP compared with non-Aboriginal HD patients. Despite having higher BP, Aboriginal HD patients received the same mean number of antihypertensive agents as non-Aboriginal patients. Although speculative, these differences may reflect less aggressive BP management for Aboriginal HD patients or may reflect greater interdialytic weight gain for Aboriginal patients, a variable that was not assessed in this study. Although the long-term impact of inadequate BP and mineral metabolism control on morbidity and mortality in Aboriginal HD patients is unknown, we hypothesize that these factors may contribute to the higher age-adjusted mortality rate in Aboriginal compared with non-Aboriginal HD patients (29).

To assess the possibility that survivor bias may have influenced the results in this cross-sectional study, we conducted a further analysis stratified for duration of dialysis (<2 yr and >2 yr). The results of this analysis were essentially identical to that reported; therefore, survivor bias is unlikely to explain the findings.

An important strength of our study is its population-based nature and use of patient self-report to determine racial status. Previous studies regarding racial disparities in HD populations have relied on administrative data sets to obtain racial classification, with the limitations and potential for misclassification well documented (30,31). To the best of our knowledge, this is the first study to report potential racial inequities in HD care on the basis of self-report of racial status.

Our study has limitations. First, given its cross-sectional design, we could not assess the impact of HD adequacy on prospective outcomes such as morbidity and mortality. Second, we did not have information on compliance with therapy, socioeconomic status, and dietary intake, all of which may potentially influence adequacy of care, and in particular the differences in mineral metabolism and BP control observed. Third, racial status was dichotomized into Aboriginal and non-Aboriginal, which may obscure potential differences between other non-Aboriginal races. However, similar results were obtained in a sensitivity analysis that compared only white HD patients with Aboriginal HD patients. Finally, the study was based on HD patients in a single Canadian province, which may limit its generalizability.

Despite these limitations, results from our study suggest similar quality of HD care for Aboriginal and non-Aboriginal HD patients. Although differences in predialysis BP control and mineral metabolism were present, these differences may be explained by other unmeasured factors, such as compliance, socioeconomic status, and dietary intake. Future studies are required to identify reasons for these differences in BP control and mineral metabolism to enable targeted interventions to be developed in partnership with the Aboriginal communities.


   Acknowledgments
 
This study was supported by the Alberta Kidney Disease Network. Drs. Tonelli, Gourishankar and Hemmelgarn are supported by Population Health Awards from the Alberta Heritage Foundation for Medical Research. Drs. Tonelli and Hemmelgarn are also supported by New Investigator Awards from the Canadian Institute of Health Research.


   Footnotes
 
Published online ahead of print. Publication date available at www.cjasn.org.

Received July 27, 2005. Accepted October 8, 2005.


   References
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 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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