Addressing Chronic Kidney Disease An eGFR Community Engagement Playbook

Addressing Chronic Kidney Disease

An eGFR Community Engagement Playbook

By the Office of Diversity, Equity, Inclusion and Belonging

Table of Contents

Introduction

○ Executive Summary and Purpose

○ Background and History

○ Alignment to CommonSpirit Mission and Goals

○ Project Priority: Creating Awareness and Building Access to Care

Applying the Playbook

○ eGFR Project Goals

○ Stakeholders, Project Team, and Project Plan

○ Timeline of Events

○ Project Plan

○ Establishing KPIs

○ Budgets & Grants

Engaging Community Partners

○ Marketing & Communications Guide

○ Engaging Community Health and Community Partners

Tips for Having Health Equity Conversations FAQs

Introduction

Equity is Everlasting:

Health Equity means everyone has a fair and just opportunity to be as healthy as possible.

~Office of Diversity, Equity, Inclusion & Belonging (CommonSpirit Health)

Executive Summary and Purpose

In 2022, CommonSpirit Health began adoption of The National Kidney Foundation (NKF) and the American Society of Nephrology (ASN) guidance recommendations for healthcare providers to transition to a new calculator for the estimation of Glomerular Filtration Rate (eGFR), which estimates kidney function without a race variable. This effort was reviewed, approved, and prioritized by CommonSpirit Health’s Board of Stewardship Trustees and Chief Executive Officer, Wright L. Lassiter III.

By 2023, all CommonSpirit Health Laboratories had transitioned, including all CommonSpirit affiliated labs and partnerships with LabCorp, Associated Regional and University Pathologist (ARUP), and Quest Diagnostics.

In conjunction with the laboratory changes, CommonSpirit successfully launched a community-facing campaign to address the impacts that a historically biased eGFR calculation had on the African American community.

The vision of the Office of Diversity, Equity, Inclusion, and Belonging (ODEIB), and CommonSpirit Health, is to continue this work across our markets to improve equity in kidney health access and outcomes for all communities we serve.

The purpose of this playbook is to support any CommonSpirit geography to rapidly replicate the community awareness, education, and partnership program to benefit the communities we serve.

Background And History

Chronic Kidney Disease (CKD) affects 37 million American adults. 90% are undiagnosed and unaware of their condition, Black Americans are about 4 times more likely to suffer from kidney failure and Hispanic/Latinos 1.3 times. Disparities in CKD risks increase significantly for communities of color due to such factors as lack of access to care for early diagnosis, timely referral to nephrology, and transplant evaluation.

For decades medical professionals used an eGFR calculator that included a variety of factors to measure kidney function, including age, sex, race and/or body weight. However, recent studies suggest there is no scientific basis for including race in the algorithm.

Thus, the National Kidney Foundation and the American College of Nephrology adjusted their guidelines to recommend use of an eGFR calculator that does not include race as a factor.

Utilization of the calculator with the race factor overestimated kidney function and particularly impacted Blacks/African Americans.

This very likely resulted in care delays, loss of opportunity for disease management through lifestyle and medication, and poorer clinical outcomes for those affected by delayed diagnosis.

Old eGFR Calculation

The CKD-EPI equation, expressed as a single equation, is:

GFR = 141 * min(Scr/κ,1)α * max(Scr/κ, 1)-1.209 * 0.993Age * 1.018 [if female] * 1.159 [if black]

Newer, more equitable eGFR Calculation

The 2021 CKD-EPI equation, expressed as a single equation, is:

GFR = 141 * min(Scr/κ,1)α * max(Scr/κ, 1)-1.209 * 0.993Age * 1.018 [if female]

Alignment to CommonSpirit Mission and Goals

In keeping with our mission to improve the health of the people we serve while advancing social justice for all, CommonSpirit Health began system-wide work removing the eGFR race-based calculator from use in 2022. By 2023, all CommonSpirit laboratories were utilizing the updated calculator, marking a significant step towards equitable diagnosis of chronic kidney disease for Black/ African American patients and other people of color.

In addition to the lab transitions, Commonspirit developed Equity Heals: Addressing Chronic Kidney Disease, a community outreach, awareness and education initiative launched in February 2023.

This pilot initiative, designed by ODEIB, enabled partnership with Dignity Health St. Joseph’s Hospital and Medical Center in Phoenix, Arizona to engage community stakeholders also committed to health equity.

This pilot involved significant collaboration within CommonSpirit and across multiple community stakeholders. This playbook was developed to act as a guide for other hospitals and health equity champions to impact community awareness and kidney disease improvements in their communities.

Project Priority: Creating Awareness and Building Access

Effective health equity work requires engagement with:

1) Our patients to strive for equitable outcomes

2) Our employees to ensure we have diversity, equity, and inclusion embedded in our approaches to patient care, and

3) Our communities to build awareness and education to improve outcomes for those at the highest risk.

From February 2023 to December 2023, more than 50 community stakeholders were engaged to provide input on outreach strategies. Over 900 community members within the prioritized population took the National Kidney Foundation’s 1-minute risk screening quiz (Are you the 33% Campaign). More than 20 community partners have joined with us to outreach and educate those most at risk, and 15 outreach and awareness events were conducted.

Grant dollars were secured from Quest Diagnostics through the Quest for Health Equity initiative under the Quest Diagnostics Foundation. The grant specifically provided resources to deliver community based clinical screenings so underserved communities could obtain updated lab results at no cost.

The following pages will describe important steps to replicate similar objectives to engage community partners to deliver alongside your healthcare team(s).

Applying the Playbook

eGFR Project Goals

As part of CommonSpirit Health’s Health Equity Blueprint for Action and our Five Health Equity Priorities, ODEIB is working to embed health equity throughout the ministry.

The Equity Heals: Addressing Chronic Kidney Disease program supports our priority to standardize equitable and whole person care.

ODEIB partnered closely with our Clinical Standards and Variation Reduction team In 2022, the Clinical Standards and Variation Reduction team launched an initiative to address clinical calculators which includes race as a coefficient, as identified by Vyas et al. in Hidden in Plain Sight and reports of the Ways and Means Committee Report of the US Senate. As a result, the CSVR team's initiative aligned CommonSpirit Health with the recommendation from National Kidney Foundation and the American Society of Nephrology to transition to the new estimation of Glomerular Filtration Rate (eGFR) 2021 CKD-EPI creatinine equation. The calculator to diagnose chronic kidney disease, known as eGFR, has been updated due to inherent disparity for patients of African American versus non-African American descent.

The team leveraged the Institute for Healthcare Improvement’s (IHI) continuous quality improvement process by identifying partner teams and drivers of change, as well as tracking and communicating progress and key information to clinical and operational teams.

In addition, the following supporting actions were completed:

● Hosted multiple CME events for physicians and advanced practice providers reviewing reason and need for change

● Amended eGFR laboratory reports to communicate change, including date of change

● Hosted CMO meetings and town halls for administrative leaders to learn about change

● Hosted town hall discussing the change with community-based partners, including patient groups

● Communicated with external laboratory organizations to ensure change is reflected in their calculation

● Collaborated with Office of Diversity, Equity, Inclusion and Belonging to engage with community members

eGFR Project Goals

As a result, in May 2023, CommonSpirit became one of the largest health systems to transition all 140 facilities to the updated eGFR equation. Through this change, early diagnosis will result in earlier referral for treatment of chronic kidney disease for patients, thus decreasing disability and improving mortality associated with chronic kidney disease.

As CommonSpirit has fully transitioned to the equitable 2021 eGFR calculator, hospitals and regions can choose how to approach engaging constituents for any further clinical education that may be needed, as well as patient outreach, education, and clinical access.

This playbook is focused on community outreach and awareness, but acknowledges the intersectional need for close collaboration with our physician, quality and community health partners.

Equity Heals Project Goals

● Communicate changes in eGFR

● Patient Experience Focus/Survey

● Education on early transplant for patients and donors

● Care navigation, including transplant list

● Document care plan and changes over time

● Co-morbidities and Lifestyle management

● Links to CHI, Dignity Health, and Virginia Mason patient-facing pamphlets for your clinical area

○ Directions to download/print

Community Education

Clinical Screening Patient Outreach

● Identify partners in community who have trusted relationships in the African American community

● Collaborate with National Kidney Foundation and local kidney foundation chapters

● Deploy community facing communication on eGFR

● Host event(s) to support kidney health for African American Communities and other communities of color

● Include Donor education & awareness

● Identify and build collaborative opportunities for sustainable impact

At a System level, there have been several communications to providers around the equitable calculator, diagnosing patients, and holding health equity conversations with patients on this topic. These include:

● Physician and APP Toolkit

● Clinical Updates/Grand Rounds

● Lab memo

● Lab Report Language

● Direction on patient education through health equity conversations

● Socio-demographic considerations during risk assessment

● Physician Enterprise Resource Library

● Physician Enterprise news release

Stakeholders & Project Team: Identifying Internal Champions

Successful projects need executive champions to pave the way for allocating time and resources, detailing the vision, and removing barriers that impede progress.. Listed below are some potential executive sponsors / champions, as well as key project leaders and members.

Executive sponsors / champions

● Region President

● Hospital President

● Region Mission VP

● Region Physician

Enterprise VP

Project members

● Local Events Coordinator

● Administrative Fellow

● Project/Program Manager

● Community Health Worker

● Community-based Organizations

Project

leaders

● MarComm VP

● CMO / Nephrologist

● Physician Champion

● Local Lab Director

● Local Community Health Director

● Regional or Local Health Equity Liaison

We acknowledge the many contributions made to ensure program success:

Rosalyn Carpenter, Gaye Woods, Nathan Ziegler, Anjali Jones, Shannon Twumasi, Mika Ford, Fred Mendoza, Arlene Pynadath, Nathan Tait, Max Wells, Dr. Thomas McGinn, Dr. Gary Greensweig, Dr. Ankita Sagar, and Rachael Lytle

St. Joseph Hospital: Mary Ragsdale, Dr. Victor Waters, Nicosha Corday, Sonora Crittenden, Josy Torrealva, Iris Rios, Carmelle Malkovich, and Deborah Engel

Timeline of Events and Project Plan

Getting started.

In order to facilitate work we have provided a high-level Timeline and Project Plan template for use as you begin. You should expect to add additional detail and work as your market dictates, but the following tools should support your initial planning.

The Timeline is segmented into sections titled PLANNING, IMPROVING AWARENESS AND SCREENINGS and within these segments work is color-coded for assignments between Project Management and Operations. Remember, these are estimated timeframes based on our initial Equity Heals campaign.

The Project Plan template that is linked supports the Timeline and captures some high-level Milestones you should expect to achieve.

Timeline of Events

Project Plan

● Link to downloadable Excel sheet

Key Performance Indicators (KPI) and other Process Measurables

As a team of stakeholders and project leaders, it is recommended that the team work together to identify some measurable KPIs to demonstrate progress and success. It is important that established KPIs reflect measurable change in either clinical outcomes or community access, awareness and engagement.

Some examples of KPIs that were used in the community-facing work done in Arizona include:

● Numbers of Prioritized Community members completing NKF Risk Screen(with sub-metrics by population, gender, and co-morbidity)

● Overall Numbers for Population Reached (e.g. High Risk populations)

● Number of Community Based Organizations Participating

● Number of Community Events Delivered in Underserved Communities

● Number of Media Impressions (social media, online news, and audiences reached through news coverage)

● Access to care: Number of Community members Receiving Clinical Screenings

● Number of Referrals to Clinical Services

● Number of Referrals to Social Service Supports

● Additional measurements (e.g. Clinical Improvements)

● Grant Dollars Secured to Expand Outreach and Clinical Access

Budgets and Grants

Budget

As part of each hospital’s strategy to close health equity gaps, some budget allocation may already exist to support an Equity Heals program. Please check with your local leadership teams including Community Health Improvement/ Community Benefits, Quality, or Physicians for more details and / or reach out to the Office of Diversity, Equity, Inclusion and Belonging via this link. Budget needs for program delivery might consist of hosted/partnered community events, food & beverage, printed educational materials, mar/comm, and evaluation.

Recommendations:

Grants

There are numerous grant opportunities available to support community program interventions that address health disparities. CommonSpirit’s philanthropy department can provide support to identify grant opportunities and materials preparation for submission.

Related to the Arizona pilot, we sought external grant support through the Quest Diagnostics Foundation and their Quest for Health Equity initiative which seeks to bridge the health equity gap in underserved communities by removing systemic barriers and increasing access to testing, screening and diagnosis.

Additionally, community partners can be valuable resources of grant dollars. Look for potential funding partners with community foundations, other chronic disease focused organizations (e.g. diabetes, heart) and public health departments who share focus on improving health disparities.

Another example the Mission & Ministry Fund provides a number of tools and resources for community health programs including:

● Healthy Community Coalition Development

● Program Development & Evaluation

● Evidence-based Approaches and Programming

● Data Tools & Mapping

● Advancing Health Equity

Engaging Community Partners

Marketing and Communications Guide

In an effort to support communications around this important work, the CommonSpirit Communications team has developed a toolkit for hospitals and regions to draw upon as this work is scaled across the organization. These resources should be augmented with consultation from your local marketing and communications leaders.

The toolkit provides resources for:

● Internal communications for announcements and newsletters,

● External communications to support social media, media and press release development, website content, and videos on CKD facts and the eGFR change at CommonSpirit

● Patient communications to support conversations in patient care settings

● Physician communications for communications on the background of the eGFR calculator as well as informational resources from the Grand Rounds on this topic

Engaging Community Health Team and Community Partners

Our hospitals’ Community Health teams have existing relationships in their communities that can be leveraged as support for this project. When this work was launched in Phoenix, some key partners were the National and Arizona Kidney Foundations, Quest Diagnostics, Greater Phoenix Urban League, Phoenix (AZ) Chapter of The Links, Incorporated, Black Nurses Association, Equality Health Foundation, and the African American Christian Clergy Coalition.

The support and alliance from these organizations was paramount in the outreach efforts to the community to create awareness for and execution of events.

Additionally, these partnerships aided in providing voice to local issues and concerns around healthcare delivery, historical mistrust, lack of access and social drivers of inequities.

Investing in and with communities to advance health improvements and disparity elimination is an evidence-based intervention practice. Hospitals must work to get proximate to those most impacted to truly create lasting impact. Our pilot framework emphasized collaboration, integration with existing community health improvement efforts, a commitment to examine the root causes of disparities and social justice.

Examples of Community Partners in AZ related to eGFR work:

● African American Christian Clergy Coalition

● Arizona Jazz Festival

● Arizona Black Nurses Association

● American Diabetes Association

● Black Chamber of Commerce

● Black Mother’s Forum

● Coalition of 100 Black Women

● Equality Health Foundation

● Foundation for Senior Living

● Greater Phx. Urban League

● Global Nomad Trust Group

● National Kidney Foundation of AZ

● Mercy Housing

● Tanner Community Development center

Tips for Having Health Equity Conversations

An Acknowledgement of Social Injustice

It is important to note the power of acknowledgement in the long term existence of racial disparities in our society and the structural complexities that contribute to root causes when embarking on any journey to improve Health Equity.

As we identify and name various health injustices, we must then work to deeply understand their impacts on clinical outcomes and the personal ramifications endured by the impacted communities. With each of these steps, emphasis is placed on the value of respect, curiosity and listening to the voices of those most affected.

The Restorative justice framework is an excellent tool to guide community health improvement as it broadens the definition of healing to include prioritizing accountability for the social conditions that have contributed to healthcare inequities, promotes collaborative repair and health equity through inclusion while building community and provider trust.

Once we have centered ourselves with historical data and community input, we can begin the work of engaging and healing.

The following page may serve as a guide as you develop content, outreach to community partners, and engage with healthcare professionals to address and correct health disparities.

Framework for Health Equity

Conversations

Please leverage existing trainings available in Pathway that address implicit biases and some best practices for approaching health equity conversations

✓ Value and respect others’ perspectives and experiences, especially when their voices are from historically silenced communities

Do:

■ Engage in dialogue that allows for open-ended discussion

■ Ask how you can help (e.g. offering advice, providing solutions, or just listening)

■ Ask clarifying questions or rephrase what they said in your words to ensure you understand what they’re trying to say

■ Ask questions to encourage them to talk or open up

Do not:

■ Make jokes, use sarcasm or make trivial comments about a person’s identity or experiences

■ Make assumptions about a person based on their attributes

■ Diminish the importance of another person’s identity

■ Tell other people how to feel or what to think about their own experiences

■ Tell someone they’re “overreacting” or try to correct their thoughts / feelings or blame them

■ Speak over a person as they are telling their story

✓ Listen deeply with humility, respect, and empathy:

○ Be present: we speak slower than our brains work. It’s our individual responsibility to stay engaged

○ Don’t put technology between you

○ Meet the speaker’s eyes 80% of the time and allow your eyes to roam 20% as you process what is being relayed to you

○ Nonverbal feedback like nodding, facial expressions, and signs of recognition have a tremendous impact

○ Position your body to create a safe, welcoming space for the other person to speak openly. You can lean in slightly, open your chest, pull your shoulders back, and fold your hands gently

Some Tips and Phrases for having health equity conversations

Whether in community or with patients, it’s important to be respectful and come from a place of listening and trying to understand. Slow down your thoughts and put your own ideas to the side.

Start with acknowledging the person’s lived experience:

● Show compassion

● Listen and accept their experiences as real to them

● Acknowledge that bias exists, people are impacted by it, and that we have work to do to eliminate discrimination

● Validate the other person:

○ Start by listening and making eye contact

○ Put away any distractions, so they know they have your full attention.

○ Try to imagine how you might feel if you had experienced what they experienced

I can’t imagine an experience like that. I can’t imagine how hard it must be to learn this.

I understand how you’d feel hurt after learning about this. I am here to listen.

How are you feeling?

I understand the injustice of this history, and we can take a moment to sit with or talk about that.

How can I help? I am here to listen, talk, or support how it’s helpful. Can you help me understand more?

FAQs

FAQs

How should I address the question, “How could something like this happen?”

Here is brief overview of the origins of the original eGFR calculator algorithm that explains the inclusion of the coefficient identifying race as a factor in scoring.

How is this going to be funded in my market or region?

Hospitals should seek partnership with the Community Health Improvement/Community Benefit teams for potential funding support. Consider community health needs assessment priorities that may align with this chronic disease or related comorbidities. Quality may be another funding partner. Finally, consider external funding sources through community foundations, CMS, and innovation funders.

How do you overcome the barrier of distrust in the healthcare system?

Distrust of the healthcare system is a risk factor for poorer health. This has been shown true, even after adjusting for factors such as access to care, insurance, economic status and education. Minority groups show higher rates of distrust stemming from a legacy of discrimination, negative experiences and continued differences in health outcomes. The American Academy of Family Physicians suggest an engagement framework to ask the right questions, acknowledge concerns, and ascend to greater rapport as optimal.

What if I want to do research based off this finding in eGFR?

This will be a challenge in some markets as a result of not having a ‘closed-loop system’. Meaning, often times once a patient is referred out to a nephrologist or specialist, we lose line-of-sight of that patient and do not have access to data to capture and measure outcomes. This was the case in our AZ market at the time of campaign rollout. The benefits of a closed-loop system may allow for a longitudinal view of health improvement.

Can this satisfy a regulatory requirement for a health disparity?

Yes! Please reference the link to the CMS guide for applicable metrics

Are consultative services available?

Yes! If you need any additional advisory services as you plan or rollout this project, please create a request.

Access to Nephrologists is limited in my area. How do we work around this?

View this as an opportunity to leverage in-network providers, community providers, and FQHCs. We encourage you to reach out to Physician Enterprise resources for additional advice.

Appendix

Example: Invitations to Participate for Leaders

MEMORANDUM

TO:

FROM: (Core Team, including clinical and administrative leaders)

Date: January xx, 2023

RE: Health Equity LTIP Goal FY23

As part of CommonSpirit’s ongoing commitment to addressing healthcare access and improving the health of the people we serve, {Insert hospital name} is embarking on a community-facing awareness and education campaign.

Following an internal review of clinical calculators, recommendations from professional societies, and nationally recognized clinical best practices, the calculation of kidney function, also known as the estimated glomerular filtration rate (eGFR) had a strong recommendation from the National Kidney Foundation and the American Society of Nephrology to use an updated version of the calculator that rectifies any potential disparity and makes the calculator much more accurate across all patient populations. In response, CSH transitioned our facility-based laboratories to the 2021 CKD eGFR equation/calculator. This change is a beginning point of closing disparity in care by facilitating early diagnosis of chronic kidney disease, which in turn initiates early treatment of chronic kidney disease and early evaluation for kidney transplants.

In addition to the lab transitions, we are undertaking additional measures to increase awareness, education and improved health outcomes. A project team combining [insert departments / names} is working to develop additional intervention points of impact for patients in the clinical setting and for the broader community.

Over the next {insert timeframe}, our hospital is designing and launching a community outreach and engagement project focused on CKD disparities impacting African American and Black populations. We are currently inviting feedback and stakeholder identification as we pull together a collaborative team designated to lead this important work. You have been identified as an expert in your area whose expertise and leadership will provide insight and knowledge to effectively reach community members and patients.

We are planning a virtual kick-off on {insert date}, to further describe the work’s concepts and goals. A calendar invite will follow this email. We look forward to working with you!

Example: Establishment of Measurable Goal

MEMORANDUM

TO:

FROM:

LTIP Core Team:

Physician Enterprise: Dr. Gary Greensweig, Dr. Ankita Sagar

Office of Diversity, Equity, Inclusion & Belonging: Dr. Nathan Ziegler, Gaye Woods, Anjali Jones

ECG: Nathan Tait

DATE: January xx, 2023

RE: Health Equity LTIP Goal FY23

The Office of Diversity, Equity, Inclusion & Belonging (ODEIB) and the Physician Enterprise would like to share information with you about the Health Equity LTIP Goal for FY 2023. This goal highlights CommonSpirit’s ongoing commitment to addressing healthcare access and improving the health of the people we serve. A project team combining ODEIB and Physician Enterprise is working to develop intervention points of impact for patients in the clinical setting and for the broader community through the development of two pilot designs, which is why we are reaching out to you.

Work related to Chronic Kidney Disease (CKD) began in 2022 following recommendations from the National Kidney Foundation and the American Society of Nephrology. These recommendations, together with an internal review of clinical calculators, led to a change in the formula we use to calculate kidney function using the Estimated Glomerular Filtration Rate (eGFR). This updated version of the calculator rectifies the disparity in early diagnosis of CKD and makes the calculator much more accurate across all patient populations. Through the efforts of the Laboratory Council and Physician Enterprise approximately 80% of Commonspirit Health’s facilities and outside partner laboratories have changed the way they calculate eGFR with the balance of facilities planned to be completed by the end of FY 2023.

The LTIP goal will not only measure the implementation of new eGFR formulas across the system, but also includes measures to increase patient and provider awareness and education, as well as to improve patient health outcomes around chronic kidney disease (CKD). The ODEIB team is tasked with designing and launching a community outreach and engagement pilot focused on CKD disparities impacting the African American population. We would very much like to work with the Arizona Market to create a pilot that can be scaled across CommonSpirit Health. We are seeking your guidance and partnership with this project, including stakeholder identification as we convene a multidisciplinary steering committee for this important work. You have been identified as an expert to provide the committee insights and knowledge to effectively implement the pilot, and by way of this memo, we cordially invite your participation in our valuable work. The ODEIB pilot design and launch are planned to occur over the next six months.

Links to Important Resources

Office of Diversity Equity Inclusion, and Belonging website

National Kidney Disease and American Society of Nephrology press release

Market Kickoff Deck that can be repurposed

New England Journal of Medicine article

National Kidney Foundation Education Material

Educational Video

Physician FAQ style information

What is eGFR? and a

history of inequity

What is eGFR?

Estimated Glomerular Filtration Rate (eGFR)

● eGFR is a measurement taken via blood test that estimates the kidney function (or filtration rate)

● Higher the eGFR = better kidney function

● Clinically used for dosing medications, radiology contrast media, and decision support for referral to dialysis or transplant

● 2 main equations: MDRD or 2012 CKD-EPI Equation are most commonly used

○ Both use age, gender, race, serum creatinine for eGFR

Equity Concern: calculator reports higher eGFR values (thus better kidney function) for patients identified as Black or African American. This may not represent the true level of kidney function. Thus, may delay referral to specialist care or listing for kidney transplantation for patients identified as black.

Results

● Stage 1: eFGR ≥ 90; kidneys work as well as normal

● Stage 2: eGFR 60-89; mild kidney damage

● Stage 3: eGFR 45-59; mild to moderate kidney damage

● Stage 4: eGFR 30-44; moderate to severe kidney damage

● Stage 5: eGFR < 15; kidney failure

Chronic Kidney Disease QRG

Additional Educational Material

History in Inequity

A 1999 landmark study proposed the current state eGFR calculator and included an artificial multiplier coefficient for Black patients on the basis of 3 flawed, small, poor quality studies. These faulty assumptions were carried forward through later iterations of the calculator. The 1999 study said that “previous studies have shown that on average, black persons have greater muscle mass than white persons” but that assertion relied on 3 small studies published in between the 1970s and 1990s.

One study looked at the body composition of roughly 240 Black and White children and said that Black children had lower body fat and different body densities; the second looked at about 40 adults and said Blacks had higher total body potassium and calcium compared with Whites; and the third, looking at 60 healthy hospital workers, said that Blacks had higher on average serum creatinine kinase levels. However, muscle mass on a living human cannot be measured, only on a cadaver. Additionally, based on recent human genome studies, we know that there are no biological differences between races.

Sociodemographic differences in clinical trial participation, rather than race, are a more likely factor in variation, and those factors could affect creatinine levels.

Possible explanations for differences in serum creatinine include muscle mass, excretion, ancestral, enzymatic, and transport processes, as well as diet, especially ones that include meat. Medications can also be a factor.

Additionally, based on recent human genome studies, we know that there are no biological differences between races. Sociodemographic differences in clinical trial participation, rather than race, are a more likely factor in variation, and those factors could affect creatinine levels.

Possible explanations for differences in serum creatinine include muscle mass, excretion, ancestral, enzymatic, and transport processes, as well as diet, especially ones that include meat. Medications can also be a factor.

In summary, conclusions were made on small and inaccurately designed studies, that assumed differences in African American patients could be solely attributed to race.

Thank You