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Key Points Disparities in predialysis nephrology care and KRT-directed education significantly influenced home dialysis underuse among marginalized populations. The influence of predialysis care disparities on home dialysis underuse lasted for a long time even after starting the dialysis. More studies are needed to uncover the layers through which structural racism influences home dialysis underuse among marginalized populations. Background Predialysis nephrology care and KRT-directed education (KDE) are essential for incident home dialysis use. However, there are substantial disparities in these care parameters among patients with advanced CKD. The effect of these disparities on home dialysis underuse has not been examined. Methods We analyzed the 2021 United States Renal Database System to identify all adult patients with kidney failure with over 6 months of predialysis Medicare coverage initiating their first-ever dialysis between 2010 and 2019. We used a mediation analysis to dissect the attributable influence of disparities in predialysis nephrology care and KDE on incident home dialysis use. In addition, we conducted sensitivity analyses using graded levels of mediators and sustained effect on home dialysis outcomes. Results We identified 464,310 Medicare recipients: 428,301 using in-center hemodialysis and 35,416 using home dialysis as their first-ever dialysis modality during the study period. Compared with non-Hispanic White patients ( n =294,914), adjusted odds ratio (95% confidence intervals) for receiving predialysis nephrology care, KDE service, and incident home dialysis were 0.62 (0.61 to 0.64), 0.58 (0.52 to 0.63), and 0.76 (0.73 to 0.79), respectively, among Hispanic individuals ( n =49,734) and 0.74 (0.73 to 0.76), 0.84 (0.79 to 0.89), and 0.63 (0.61 to 0.65), respectively, among Black individuals ( n =98,992). Mediation analyses showed that compared with non-Hispanic White individuals, lack of nephrology care explained 30% and 14% of incident home dialysis underuse among Hispanic and Black individuals, respectively ( P < 0.001). Sensitivity analyses using a longer duration of nephrology care and KDE services and the sustained effect on home dialysis underuse through the first year after kidney failure showed congruent and consolidating findings. Conclusions Disparities in predialysis nephrology care were significantly associated with lower home dialysis use among Hispanic and Black individuals.
Shukla et al. (Wed,) studied this question.