Community Health Center Penetration and Kidney Care Outcomes among Low-Income, Nonelderly Adults with Kidney Failure

Key Points Populations who experience health disparities often rely on community health centers (CHCs) for ambulatory care. Among low-income populations, higher CHC penetration is associated with greater preparedness for, and better outcomes after, kidney failure onset. Our study suggests that CHCs provide essential ambulatory care for nonelderly adults who experience kidney health disparities. Background In the United States, historically minoritized populations experience disproportionately high incidence of progressive kidney disease but are often unprepared for kidney failure. Owing to limited options for health care, many minoritized patients with kidney disease rely on community health centers (CHCs) for affordable ambulatory care. Methods We conducted a retrospective cohort study of 139,275 adults aged 18–64 years who were enrolled in Medicaid or uninsured at the time of ESKD onset during 2016–2020. We examined whether CHC penetration of the state-level low-income population was associated with ESKD incidence, process measures reflective of pre-ESKD care quality, and survival and kidney transplant waitlisting 1 year after ESKD onset. We obtained population characteristics of the 1370 Health Resources and Services Administration CHCs and 50 states (and DC) for the same period. Results Mean CHC penetration among low-income residents (percentage of low-income residents who were CHC patients in each state) was 36% (SD, 19%). The Northeast (census region) had the highest proportion of states with high CHC penetration, and the South had the highest proportion of states with low CHC penetration. The prevalence of diabetes mellitus, high BP, and obesity were lower in states with high versus low CHC penetration. There were no significant differences in age- and sex-standardized ESKD incidence according to CHC penetration. In individual-level analyses, higher CHC penetration was significantly associated with a higher likelihood of prolonged nephrology care (adjusted odds ratio [OR], 1.04 [95% confidence interval (CI), 1.03 to 1.05]), arteriovenous fistula or graft usage at hemodialysis initiation (OR, 1.11 [95% CI, 1.09 to 1.12]), home dialysis usage (OR, 1.04 [95% CI, 1.02 to 1.05]), and 1-year kidney transplant waitlisting (OR, 1.19 [95% CI, 1.18 to 1.21]) and ESKD survival (OR, 1.06 [95% CI, 1.04 to 1.07]). Conclusions Among Medicaid enrollees and uninsured adults with incident kidney failure, higher CHC penetration was associated with a lower prevalence of kidney disease risk factors and better preparedness for, and higher survival after, ESKD onset. These findings warrant additional study into the role and effect of CHCs in addressing long-standing disparities in kidney health.