title: The impact of social disadvantage in moderate-to-severe chronic kidney disease: an equity-focused systematic review.
abstract: It is unclear whether a social gradient in health outcomes exists for people with moderate-to-severe chronic kidney disease (CKD). We critically review the literature for evidence of social gradients in health and investigate the 'suitability' of statistical analyses in the primary studies. In this equity-focused systematic review among adults with moderate-to-severe CKD, factors of disadvantage included gender, race/ethnicity, religion, education, socio-economic status or social capital, occupation and place of residence. Outcomes included access to healthcare, kidney disease progression, cardiovascular events, all-cause mortality and suitability of analyses. Twenty-four studies in the pre-dialysis population and 34 in the dialysis population representing 8.9 million people from 10 countries were included. In methodologically suitable studies among pre-dialysis patients, a significant social gradient was observed in access to healthcare for those with no health insurance and no home ownership. Low income and no home ownership were associated with higher cardiovascular event rates and higher mortality [HR 1.94, 95% confidence interval (CI) 1.27-2.98; HR 1.28, 95% CI 1.04-1.58], respectively. In methodologically suitable studies among dialysis patients, females, ethnic minorities, those with low education, no health insurance, low occupational level or no home ownership were significantly less likely to access cardiovascular healthcare than their more advantaged dialysis counterparts. Low education level and geographic remoteness were associated with higher cardiovascular event rates and higher mortality (HR 1.54, 95% CI 1.01-2.35; HR 1.21, 95% CI 1.08-1.37), respectively. Socially disadvantaged pre-dialysis and dialysis patients experience poorer access to specialist cardiovascular health services, and higher rates of cardiovascular events and mortality than their more advantaged counterparts.
authors.affiliation: School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
authors.forename: Rachael Lisa
authors.initials: RL
authors.lastname: Morton
authors.affiliation: Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
authors.forename: Iryna
authors.initials: I
authors.lastname: Schlackow
authors.affiliation: Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
authors.forename: Borislava
authors.initials: B
authors.lastname: Mihaylova
authors.affiliation: Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
authors.forename: Natalie Dawn
authors.initials: ND
authors.lastname: Staplin
authors.affiliation: Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
authors.forename: Alastair
authors.initials: A
authors.lastname: Gray
authors.affiliation: Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
authors.forename: Alan
authors.initials: A
authors.lastname: Cass
mesh_terms: D018450:Disease Progression; D000069576:Health Equity; D054624:Health Status Disparities; D054625:Healthcare Disparities; D006801:Humans; D051436:Renal Insufficiency, Chronic / Q000453:epidemiology* / Q000473:pathology / Q000628:therapy; D012959:Socioeconomic Factors
keywords: causal pathways; chronic kidney disease; inequalities; systematic review