Algorithmic Changes Are Not Enough: Evaluating the Removal of Race Adjustment from the eGFR Equation

TL;DR

Removing race adjustment from eGFR equations alone does not significantly change nephrology referral rates among Black patients, indicating that structural inequities require broader interventions beyond algorithm modifications.

Contribution

This study empirically evaluates the clinical impact of removing race adjustment from eGFR equations on healthcare disparities in CKD management.

Findings

No significant change in nephrology referral rates after removing race adjustment

Estimated referral rates remained nearly identical with or without race adjustment

Structural inequities persist beyond algorithmic changes in CKD care

Abstract

Changing clinical algorithms to remove race adjustment has been proposed and implemented for multiple health conditions. Removing race adjustment from estimated glomerular filtration rate (eGFR) equations may reduce disparities in chronic kidney disease (CKD), but has not been studied in clinical practice after implementation. Here, we assessed whether implementing an eGFR equation (CKD-EPI 2021) without adjustment for Black or African American race modified quarterly rates of nephrology referrals and visits within a single healthcare system, Stanford Health Care (SHC). Our cohort study analyzed 547,194 adult patients aged 21 and older who had at least one recorded serum creatinine or serum cystatin C between January 1, 2019 and September 1, 2023. During the study period, implementation of CKD-EPI 2021 did not modify rates of quarterly nephrology referrals in those documented as Black or African American or in the overall cohort. After adjusting for capacity at SHC nephrology clinics, estimated rates of nephrology referrals and visits with CKD-EPI 2021 were 34 (95% CI 29, 39) and 188 (175, 201) per 10,000 patients documented as Black or African American. If race adjustment had not been removed, estimated rates were nearly identical: 38 (95% CI: 28, 53) and 189 (165, 218) per 10,000 patients. Changes to the eGFR equation are likely insufficient to achieve health equity in CKD care decision-making as many other structural inequities remain.