Care Gaps for Women with CKD in the United States

Background: There are reported sex differences in the etiology, population prevalence, progression rates, and health outcomes of people with chronic kidney disease (CKD). Whether these differences are explained by differences in health care is unknown. Therefore, we compared key health care indices in men vs. women newly diagnosed with CKD Methods: Epic Cosmos is a nationally representative electronic medical record (EMR) cohort that includes more than 300 million patients across 238 U.S. health systems and representing patients in all 50 states. Using Cosmos, we identified all adults (aged ≥18 and <90 years) who had suspected (n=7.86 million) or confirmed (n=1.62 million) incident CKD between January 1, 2017 and June 30, 2023. Suspected CKD was defined as one outpatient eGFR<60 ml/min per 1.73 m2 without a history of CKD, and confirmed CKD was defined as two outpatient eGFR<60 ml/min per 1.73 m2 within 3 months and with no prior history of CKD. Primary outcomes were: 1) retesting of eGFR within 3 months of first eGFR among suspected CKD, and 2) provider recognition of CKD defined as an ICD-10 code for CKD within 18 months of second eGFR among confirmed CKD. Crude logistic regression and Cox proportional hazards modelled the association between sex and eGFR retesting and provider recognition, respectively. Results: Among those with suspected CKD, 49.5% of women and 57.7% of men had eGFR retested within 3 months, with women were ~28% less likely than men to have eGFR retested (odds ratio: 0.719 [95%CI: 0.716-0.721]). Among those with confirmed CKD, 27.8% of women and 37.2% of men had a CKD diagnosis code recorded in their EMR, with women ~23% less likely than men to have received a CKD diagnosis (HR: 0.766 [95%CI: 0.762-0.771]). Conclusion: In this nationally representative study, a large proportion of both men and women with suspected or confirmed CKD are not receiving guideline-recommended retesting or recognition of CKD in their EMR, likely impeding downstream care processes such as prescription of medications, specialist referrals and annual monitoring. Importantly, these care gaps disproportionality impact women and understanding the causes of differential care by sex is an imperative next step to mitigating inequalities.