Document Type

Thesis - Open Access

Award Date

2024

Degree Name

Master of Science (MS)

Department / School

Mathematics and Statistics

First Advisor

Semhar Michael

Abstract

Background: This systematic review and meta-analysis aimed to examine the influence of social determinants of health (SDOH) on End-Stage Kidney Disease (ESKD) mortality among diverse racial populations. Given the high morbidity and mortality associated with ESKD, understanding the impact of various SDOH factors across different racial groups is crucial for improving patient outcomes.
Methods: A comprehensive literature search was conducted to identify studies reporting on the relationship between SDOH and ESKD mortality using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) format. Citations were collated in EndNote 21 and screened in Covidence by two independent reviewers, with inter-rater reliability assessed using Cohen’s kappa. Eligible studies involved U.S. adults over 18, measuring at least one SDOH, diagnosed with ESKD, and initiating dialysis. Methodological quality was appraised using JBI instruments by two independent reviewers, with discrepancies resolved through discussion or a third reviewer. All studies were included for data extraction regardless of quality scores. Data, including author, publication year, sample sizes, effect sizes, confidence intervals, and outcomes, were extracted using Covidence. Discrepancies were resolved through discussion or with a third reviewer, and authors were contacted for missing data. The meta-analysis primarily included studies reporting hazard ratios, using a random effects model to calculate pooled estimates and confidence intervals to accommodate between-study heterogeneity. For education, a fixed effects model was used due to significance in the results of the model.
Results: A total of 1,828 studies were initially identified, and after thorough screening and application of eligibility criteria, 85 studies were included in the systematic review. The findings indicate that White populations have a higher risk of dying from ESKD compared to racial minorities, even after accounting for various social determinants of health (SDOH). Specifically, the risk of ESKD mortality was 19% lower in Black populations (HR 0.81, 95% CI 0.77-0.85), 38% lower in Asian populations (HR 0.62, 95% CI 0.59-0.66), and 16% lower in Native American populations (HR 0.84, 95% CI 0.80-0.87) compared to White populations. Hispanic populations had a 26% lower risk compared to Non-Hispanic White populations (HR 0.74, 95% CI 0.53-1.03) and a 9% lower risk compared to Non-Hispanic populations (HR 0.91, 95% CI 0.78-1.10), though these findings were not statistically significant. Additionally, urban patients experience an 8% lower risk of ESKD mortality compared to rural patients (HR 0.92, 95% CI 0.88-0.96). Higher education levels were associated with a 10% lower risk of ESKD mortality (HR 0.90, 95% CI 0.83-0.97).
Conclusion: The study demonstrates that social factors like race, insurance, education, and location significantly impact ESKD mortality. White patients have higher mortality rates, while minorities experience severe complications despite receiving equal care. Uninsured rural patients also have higher mortality rates. Higher education and urban living lead to improved outcomes. Targeted policies and infrastructure improvements are vital to address these disparities.

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