Balancing Efficiency and Equity in Screening for Chronic Kidney Disease
Balancing Efficiency and Equity in Screening for Chronic Kidney Disease
More than one in seven adults in the United States are believed to have chronic kidney disease, with the burden disproportionately impacting Black and Hispanic adults. A new Stanford study suggests a population-wide CKD screening could reduce these disparities.
Screening for chronic kidney disease at younger ages could prolong life expectancy and reduce health disparities among racial and ethnic groups—particularly for non-Hispanic Black adults, who are disproportionally affected by CKD, according to a new Stanford study.
More than one in seven adults in the United States, or about 35.5 million people, are believed to have chronic kidney disease (CKD), though many don’t know it. The burden of CKD disproportionately impacts racial and ethnic minority groups; the lifetime risk of kidney failure requiring dialysis or a kidney transplant is more than three times higher for non-Hispanic Black adults and 1.5-fold higher for Hispanics compared to non-Hispanic white adults.
While non-Hispanic Black adults make up 12% of the population, they account for 24% of kidney transplant and dialysis cases in this country. These disparities are often driven by factors such as the lack of health care and insurance, along with other social determinants like where people live, their education, as well as the racial discrimination and structural inequality in American society.
In an original investigation published in JAMA Network Open, a team of Stanford Health Policy researchers evaluated the health benefits and cost-effectiveness of screening for chronic kidney disease in different racial and ethnic groups. Using data from clinical trials, published cohort studies, and Medicare records, the researchers used a simulation model to analyze CKD progression in four adult groups: Hispanics, non-Hispanic Blacks, non-Hispanic whites and other racial/ethnic groups.
“Previous studies have reported disparities in kidney failure among racial and ethnic minorities, particularly non-Hispanic Black adults,” said Marika M. Cusick, a PhD student in health policy and lead author of the study. “Our analysis suggests that population-wide chronic kidney disease screening may help reduce disparities, as it yields the greatest health benefits for non-Hispanic Black adults.”
Getting the Word Out
A tailored messaging and outreach efforts to promote screening engagement among non-Hispanic Black adults, Cusick said, are key to addressing inequities in the nation’s CKD outcomes.
The research team previously demonstrated that population-wide screening for chronic kidney disease in the era of SGLT2 inhibitors—a class of medications to treat type 2 diabetes that also benefit heart and kidney health—reduced the burden of kidney failure and was cost-effective. Now focusing specifically on health benefits and costs by racial and ethnic groups, they found that starting to screen for CKD at age 55 was the most cost-effective overall—but starting at younger ages would help reduce disparities even more.
Cusick and the team found that without any CKD screening, non-Hispanic Black adults had the highest lifetime risk of kidney failure, at 6.2%, compared to Hispanics at 3.6%, other racial and ethnic groups like Asians and Native Americans at 3.3% and non-Hispanic whites at 2.3%. Screening every five years ages 55 to 75, along with SGLT2 treatment, reduced kidney failure and increased life expectancy for all groups.
The researchers found the biggest benefit would be for non-Hispanic Black adults, who could have a 0.08 percentage point lower incidence of dialysis or kidney transplantation and gain about 0.19 more life years. The cost of screening every five years for the overall U.S. population would be about $99,100 for each added year of good health—called a QALY, or Quality-Adjusted Life Year. For every group studied, this strategy cost less than $150,000 per QALY, a common threshold for cost-effectiveness, with the lowest cost for non-Hispanic Black adults at $73,400 per QALY.
Benefits Compounded at Younger Age
“Although screening every five years starting at age 55 was cost-effective for the overall U.S. population, initiating screening at younger ages, say 35 or 45, would further reduce CKD disparities—especially for non-Hispanic Black adults,” said Jeremy D. Goldhaber-Fiebert, PhD, a professor of health policy and senior author of the study. “Policymakers should balance efficiency and equity objectives when evaluating optimal population-wide screening strategies.”
The researchers found that screening every five years from ages 55 to 75 could prevent 689,000 cases of chronic kidney disease overall. It was most effective for Hispanic, Non-Hispanic Black, and other racial/ethnic groups—preventing about 60+ cases per 10,000 people screened, compared to 33 for non-Hispanic white adults. If screening earlier started at age 35, the researchers found that screening could prevent 27,000 more cases, with a third of those among non-Hispanic Black adults. Screening at age 35 was only cost-effective for non-Hispanic Black adults.
The other authors of the study are Rebecca L. Tisdale, MD, MPA, physician and health services researcher at the VA Palo Alto Healthcare System; Alyce S. Adams, PhD, MPP, professor of health policy; Glenn M. Chertow, MD, MPH, professor of medicine at Stanford Medicine; Douglas K. Owens, MD, MS, professor of health policy and chair of the Department of Health Policy at Stanford Medicine; and Joshua Salomon, PhD, professor of health policy.
