ABSTRACT
BACKGROUND: Underserved patients, including racial/ethnic minorities, and patients with limited English proficiency, experience worse chronic kidney disease (CKD) outcomes. Appropriate CKD care requires timely attendance upon nephrology referral and primary care co-management with nephrologists. Outcomes in these populations may be impacted by delays in access to subspecialty care and referral timeliness. The goal of our study was to assess the association of language, race, and ethnicity with ambulatory metrics among patients referred to nephrology clinics. METHODS: We used EHR data from an academic hospital in Boston to compare ambulatory metrics among patients referred to in-person nephrology visits between 2019-2021.We examined 1) percentage of no shows among all nephrology visits (new and established) and 2) average new visit delay (calendar days between referral date and scheduled date). We compared outcomes based on patient-reported language preference (non-English vs English), race (Black vs White), and ethnicity (Hispanic vs non-Hispanic). To account for changes over time during the COVID-19 pandemic, metrics were compared visits during three timeframes;10/01/19-12/31/19, 10/01/20-12/31/20, and 10/ 01/21-12/31/21. RESULTS: We identified 12,034 nephrology visits. Subtotals were 10,748 English, 1276 non-English, 7246 White, 2406 Black, 10,081 non-Hispanic, and 1534 Hispanic. We found significant disparities in no show rates which persisted across all three timeframes. In 2019, non-English speaking patients had an 11.6% no show rate compared to 6.6% of English-speaking patients (p=0.001), Black patients had an 11.5% no show rate compared to 5.0% of White patients (p<0.001) and, Hispanic patients 11.8%compared to 6.6% non-Hispanic patients (p=0.002). In 2020, no show rates were 11.8% non-English vs 7.3% English, p=0.008;13.3% Black vs 5.3% White, p<0.001;and, 10.4% Hispanic vs 7.4% non-Hispanic, p=0.019. In 2021, no show rates were 11.9% non-English vs 6.1% English, p<0.001;11.3% Black vs 4.3%White, p<0.001;and, 14.3% Hispanic vs 5.7% non-Hispanic, p<0.001. Average delay for new in-person nephrology referrals were similar across demographics though did fluctuate over time (Q4 2019, 45.1 days;Q4 2020, 38.8 days;Q4 2021, 63.0 days). CONCLUSIONS: Our findings reveal disparities in no show rates for nephrology appointments. We did not find disparities in timeliness of referrals, but did see differences between time periods, presumably from COVID. Results reinforce the need for robust efforts to ensure equitable access and care engagement, taking into account the social determinants and structural inequities which contribute to these disparities. In addition, the impact of COVID on chronic disease management could be lessened by targeted attention to improvements in telehealth and PCP/specialist integration.