Does Ethnicity and IMD Influence Unplanned Access Starts?
Introduction:The incidence and prevalence of end stage renal disease is higher among racial and ethnic minority groups compared to the white population though these rates are similar in CKD.[i] In our centre we have reviewed all patients who have started on renal replacement therapy (RRT) and were known to the renal service for > 90 days. We explored the effect of Indices of Multiple Deprivation (IMD) score and ethnicity on planned versus unplanned starts and access.
Method: All incident patientswho were known to the service for more than 90 days and started renal replacement therapy in 2015 were reviewed. IMD score was calculated for each patient using ONS based quintile rank method using the patient’s postcode, the higher the IMD score the greater the level of deprivation. Ethnicity was recorded as Caucasian, Black, South Asian or Other. A planned start was defined as starting on PD,hemodialysis with a fistula or graft or preemptive transplant.
Results:The overall populationincluded 116 (55%)Caucasian, 68 (32%) South Asian, 19 (9%) Black and 8 (4%) Other. Overall 67%of patients started in a planned fashion. 72% of the Caucasian population started RRT in a planned fashion compared with 63% in the South Asian population and 47% of the black population.
65% and 83% of patients with an IMD score of 1 and 2 respectively started in a planned fashion compared to 65% and 63% of patients with IMD score of 4 and 5. There is an association of increased deprivation and ethnicity in our catchment population with only 9% of patients with IMD score 1being south Asian or black compared to72% of patients with an IMD score of 5. A variation was seen in the number of home therapies or pre-emptive transplants performed in the different ethnic groups (table 1)
Table 1: Ethnicity and modality at start of RRT
Ethnicity / HD n(%) / PD n(%) / Transplant n(%)Caucasian / 75 (65%) / 28 (24%) / 13 (11%)
Black / 17 (89%) / 2 (11%) / 0 / P <0.05
South Asian / 54 (79%) / 12 (18%) / 2 (3%)
Conclusion: There is some ethnic variation in planned starts on renal replacement therapy; the black population has a significantly lower planned start rate than both Caucasian, p<0.05, and south Asians, p<0.05..The patients who are most deprived have an increased chance of starting RRT in an unplanned fashion. There is also a difference in modality choices within the different ethnic groups with the south Asian and Black population less likely to choose a home therapy. There are cultural and medical reasons why ethnicity may affect modality choice, planned starts and pre-emptive transplant rates. Rapidity of renal decline, language barriers, travel abroad and cultural beliefs all influence the ability to prepare a patient and their modality choice.
[i] USRDS 2008