Pharmacist's Role in Reducing Medication-related Racial Disparities in African American Patients With Chronic Kidney Disease Ⅱ

6 | PATIENT MEDICATION EXPERIENCE

The role of a pharmacist is to provide patient-centered care that prevents poor medication experiences resulting from adverse effects, ineffective medications, and pill burden. In order to successfully help patients, pharmacists must understand how the medication experience may differ for people of color compared to Whites. AAs have an increased risk of developing angioedema with the use of ACE-I.45 If increased risk vs benefits are not discussed when prescribing or dispensing an ACE-I in AAs for hypertension or reducing risk of CKD progression and angioedema, this may lead to distrust and a higher likelihood of future intentional nonadherence to other medications proven to reduce CKD progression. Potentially resulting in uncontrolled hypertension and unavoidable polypharmacy.45

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Similar issues can be seen with glucose-lowering agents in diabetes. AAs with diabetes experience a 1.25 to 2.5 times higher risk than Whites of hypoglycemia with diabetes agents.46 AAs compared to Whites with CKD and type 2 diabetes had a 1.6 times greater risk of hypoglycemia and were more likely to receive sulfonylureas than SGLT-2i or GLP-1RAs, agents which have demonstrated cardiovascular and kidney benefits and are recommended by several guideline groups.

Antihypertensive nonadherence is more common among AAs than Whites which results in uncontrolled hypertension and an increased number of prescribed medications.47 One study found that AAs were less likely to be adherent to their medications if they were prescribed multiple classes of antihypertensives, taking loop diuretics and ACE inhibitors, were older, had less education, were unemployed, and had diabetes.48 AAs have higher rates of nonadherence to their cardiovascular medications compared to Whites, even with equitable access to health care. Previous studies have also linked fear of side effects, depression, stress, financial support, not accepting the diagnosis, beliefs and attitudes toward medications, and access to quality health care to nonadherence.48

Medication adherence can be affected by patient priorities; patient priorities may be very different than health care providers' priorities. Patients with kidney disease have expressed frustration that physicians' priorities for the treatment of kidney disease and hypertension take precedence over their concerns.49

One AA patient noted, “I don't think they don't get the problem … when they discovered that the kidneys were bad … then I was referred to the kidney doctor and they got me in here as soon as they could, [but] I have carpal tunnel in both hands, and I tell it to them all the time, and they go, ‘Okay,’ and they write it down, and then … nothing happens.” 49

Nonadherence to medications can be difficult for patients to discuss with their physicians. Some patients may go to extra lengths to deceive health care practitioners because they may not understand the need to take their medication and they want to avoid conflict.49

An AA participant with kidney disease in a qualitative study said, “Oh, she want me to take them potassium [pills], and I … I don't need them things every day. They got salt in ‘em, to me. They taste salty, but … I said, ‘That kind pill you – I don't think I have to take ‘em every day.’ But, when I get ready to go see [the doctor], then I take ‘em, so that there be some in the blood.” 49

Patients may also try to misguide their physicians by taking their medications less than prescribed due to financial barriers. The uninsured and Medicaid/public insurance rates for AAs are higher than for Whites (who are significantly more likely to have private insurance).50 In addition, AAs, Hispanics, and Asians less than 65 years are less likely to be eligible to enroll in Medicaid than Whites due to states with a Medicaid nonexpansion status. Since AAs with kidney disease experience poorer health outcomes and faster progression to ESKD, they also incur greater medical expenses than Whites.

With telehealth becoming widely available due to the COVID-19 pandemic, it is important to note that, although virtual visits increase patient access to health care, face-to-face patient visits with pharmacists have a higher clinical impact in terms of identifying medication therapy problems in patients who are AA, have diabetes with endorgan damage, and have CKD stages 1 to 5.51 At least one additional medication therapy problem, on average, was identified with face-to-face compared to telehealth visit.

Health system distrust is also a barrier for AAs to access the resources and skills needed to obtain, understand, and apply health information.52 For this reason, many AAs would prefer to try home remedies to treat their illnesses rather than take prescription medications.53 Disbelief of the diagnosis is especially apparent in AAs with chronic conditions such as hypertension and diabetes as patients are frequently symptom-free or the condition has been present for years before an official diagnosis. Patients may also intentionally become nonadherent to their treatments due to distrust in the medications.

Other systemic factors that contribute to low health literacy (LHL) include limited educational opportunities, racism, and lack of health information that is culturally tailored to AA patients.52 Low health literacy is more prevalent in AAs than in Whites and is a predictor of racial disparities in health behaviors, health care resources, and health outcomes. Health literacy inequities are perpetuated by racial residential segregation and discrimination which limit access to quality education and health care information. Assessment of a patient's health literacy will avoid overestimating their understanding, thus missing the opportunity to provide health information and services to accommodate the needs of their patients.52

7 | DISCUSSION AND ROLE OF PHARMACIST 

Distrust of the U.S. healthcare system, health literacy inequities, unconscious biases of healthcare providers negatively impacting quality of care, and limited access to quality healthcare all contribute to health disparities faced by AAs. These are areas in which pharmacists can address disparities since they are the medication experts and the most accessible health care professionals.54 Moreover, the workforce shortages of nephrologists leave a dearth of healthcare professionals to meet the public need for safe and effective medication use. For pharmacists to effectively address this need, strategies employed must address the health disparities and increase awareness of SED and the disproportionate impact it has on the AA community.

Pharmacists can learn more about factors influencing the health of their patients by volunteering at local community centers, churches, or schools and attending community events. Active engagement in the community will provide an opportunity to meet community leaders and understand where the power resides within the community. It is important for pharmacists to learn how healthcare agencies that provide services in the community are perceived and identify past or current periods of marginalization and mistrust. Pharmacists should build on community strengths and knowledge to learn what services and programs are needed and work with the community to develop sustainable disease prevention and health promotion programs. Umeukeje et al., found that AAs are less likely to participate in community-based CKD screenings due to reasons such as a limited understanding of CKD and its risk factors, distrust in the health system, and financial burdens.55 Therefore, addressing these barriers is the first step to ensuring that any health outreach events have a positive impact on the community. Understanding the community is crucial when providing community health outreach events and this was evident with the successful community-centered interventions, involving pharmacists, to improve Native American and AA blood glucose and blood pressure control, respectively.40,41

The AA community's distrust of the health care system stems from historical inhumane treatment, poorer health outcomes, ongoing racism due to unconscious bias and stereotyping, and the lack of representation in health care.53 One study found that trust was directly associated with use of recommended preventive services in low-income AA women. Stronger patient-provider relationships, with high levels of trust, may indirectly lead to better health through adherence to recommended preventive services.56 Addressing distrust will assist with health literacy development as it impacts the interactions with the health care system, access to health care resources, and health-related decision-making.52 The first step in addressing distrust is to become familiar with the community and patients a pharmacist serves. Allowing adequate time with each patient to listen to their concerns, learn about their health and medication beliefs, and understand their health literacy and socioeconomic barriers will build a bridge to a trusting relationship which will allow for discussion of the patient's medication experience, potential adherence issues, and health goals. Additional focus should be put on racial concordance between patients and health care providers which also creates stronger patient-provider relationships, emphasizing the importance of health care providers representing the communities they serve.

While everyone holds unconscious biases about certain racial/ ethnic groups, a lack of awareness of how these biases may influence a prescriber or pharmacist's therapeutic decisions and impact the care of a patient who may fit unconscious “stereotypes” can undermine efforts toward building a trusting relationship. Unconscious bias may lead a pharmacist to believe that he or she is making an objective assessment of a patient when the assessment is based on their personal perception. Pharmacists should reflect upon the hidden beliefs or stereotypes they have about certain racial/ethnic groups and understand how these beliefs might impact the care they provide to their patients. Additionally, being aware of the unconscious biases within the entire medical community can help pharmacists address the disparities due to prescribing patterns (SGLT-2s, ACE-I/ARBs, etc.) and advocate for their patients to receive equitable care compared to their White counterparts. Fortunately, current and recent pharmacy trainees have been advocating for antiracism to be included in the pharmacy curriculum as well as taking action to dismantle structural racism within their institution. Pharmacy schools should ensure that students have opportunities to practice in underserved communities to better prepare them to care for patients from diverse ethnic and racial backgrounds.

Pharmacists can potentially make the biggest impact on their patients' access to quality care. This includes additional screening and point-of-care testing, affordability of medications, and vaccinations. Many pharmacists provide blood pressure and blood glucose point-of-care testing which can lead to better management of hypertension and diabetes to reduce CKD progression and CVD. In addition, pharmacists should also focus on improving the identification of CKD especially in AA patients. Point-of-care testing for serum creatinine and urine albumin to creatinine ratio is available and could be assessed and utilized in community pharmacies in patients filling antihypertensive and glucose-lowering medications, targeting populations that are at high risk for kidney disease.

It is crucial for pharmacists to be aware of the most salient disparities in the communities they serve and the factors driving these disparities that result in medication non-adherence and other poor health outcomes. Gaining an understanding of the social and environmental factors that influence the health of a patient provides a realistic view of the challenges a patient may face when attempting to lead a healthy lifestyle and allows the pharmacist to work with the patient to develop a realistic medication plan.57 For example, many uninsured and underinsured patients from low-income communities are forced to choose between feeding themselves and their children or refilling their medications. A pharmacist who has insight into the challenges that patients living in poverty face can identify patient assistance programs that will assist the patient in obtaining medications at little to no out-of-pocket cost. Reducing medication financial burden is an important role for pharmacists and is one step that can be taken to improve medication adherence in AAs.

The COVID-19 pandemic has brought awareness to the racial inequities that AAs face in regard to vaccination availability, understanding, and trust. AAs have lower COVID-19 vaccination rates than Whites in the United States. This is important for pharmacists to understand in order to ensure their communities have access to the vaccine, understand the risks and benefits, and address the distrust that stems from novel medical advances being unethically tested on AAs and lack of representation in clinical trials to properly assess safety and efficacy in non-Whites.

All pharmacists, not only those who identify as BIPOC must put efforts into leading diversity initiatives, committees, task forces, and community outreach events. Unfortunately, in the fight to lessen racial health disparities and dismantle structural racism, BIPOC individuals are commonly the ones to take on the majority of the workload in addition to experiencing the effects of racism and discrimination themselves.58 This can lead to burnout and a loss in advocacy efforts within the profession. In addition, BIPOC pharmacists must have support from organizational policies and processes that guarantee safe spaces and support to speak up when they experience or observe racial discrimination. It is the responsibility of all pharmacists to contribute to an inclusive and supportive environment that encourages a sense of belonging, accountability and antiracism.58

Pharmacists are in a unique position to be a part of the solution given they are the most accessible health care professionals and there are workforce shortages of nephrologists and nephrology nurses. The issue of racial health disparities stems from the health system, provider, and patient levels and pharmacists can make a significant impact on these medication-related disparities at all levels to address distrust of the health care system, health literacy barriers, biases of providers, and inequitable access to care that AAs face. The Advancing Kidney Health through Optimal Medication Management (AKHOMM) was formed to train pharmacists and help practices incorporate a pharmacist on the care team to ensure that every person with kidney disease receives optimal medication management. Resources for pharmacists to provide equitable care to all of their patients will be provided by AKHOMM.59,60

REFERENCES 

1. National Institute of Diabetes and Digestive and Kidney Diseases. Race, ethnicity, & kidney disease. National Institute of Diabetes and Digestive and Kidney Diseases. 2021 [cited 2021 Aug 14]. Available from: https://www.niddk.nih.gov/health-information/kidney-disease/ race-ethnicity 

2. Peralta CA, Vittinghoff E, Bansal N, et al. Trajectories of kidney function decline in young black and white adults with preserved GFR: Results from the coronary artery risk development in young adults (CARDIA) study. Am J Kidney Dis. 2013;62(2):261–266.

3. Yoon SSS, Carroll MD, Fryar CD. Hypertension prevalence and control among adults: United States, 2011-2014. NCHS Data Brief. 2015; 220:1–8. 

4. Spanakis EK, Golden SH. Race/ethnic difference in diabetes and diabetic complications. Curr Diab Rep. 2013;13(6):814–823. https://doi. org/10.1007/s11892-013-0421-9.

5. Centers for Medicare & Medicaid Services (CMS). Chronic kidney disease disparities: Educational guide for primary care. Washington, DC: CMS; 2021;19. 

6. CDC. Health disparities. DASH j CDC [Internet]. 2021 [cited 2021 Aug 14]. Available from: https://www.cdc.gov/healthyyouth/ disparities/index.htm 

7. Hayward MD, Miles TP, Crimmins EM, Yang Y. The significance of socioeconomic status in explaining the racial gap in chronic health conditions. Am Sociol Rev. 2000;65(6):910–930. 

8. Boyd R, Lindo L, McLemore M. On racism: A new standard for publishing on racial health inequities [Internet]. Center for Genetics and Society. 2020 [cited 2021 Aug 14]. Available from: 10.1377/ forefront.20200630.939347/full/ 

9. Robinson K, Drame I, Turner MR, Brown C. Developing the “Upstreamist” through antiracism teaching in pharmacy education. Am J Pharm Educ. 2021;85(9):8585. 

10. Harawa NT, Ford CL. The foundation of modern racial categories and implications for research on black/white disparities in health. Ethn Dis. 2009;19(2):209–217

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