Q & A with Clarissa Diamantidis: “Trust plays a big role”

Tuesday, September 1, 2015

Clarissa Jonas Diamantidis, MD, MHS, assistant professor of medicine (General Internal Medicine and Nephrology), started her residency at Duke focused on cardiology.

“My father was a Black-Hispanic cardiologist with an interest in health disparities and access to care,” she says, “and I was intent on following in his footsteps.”

However, during nephrology rounds she became fascinated with kidney disease. Her first visit to a dialysis unit sealed the deal: “It was full of black patients hooked up to ominous-looking machines, with a striking deficiency of white patients. At that moment, I decided I wanted to study nephrology.”

One aspect of her research involves working with data from the Jackson Heart Study (JHS)—a population-based longitudinal study of African Americans in Jackson, Mississippi. She and others have created a local Duke JHS kidney disease working group to stimulate nephrology research using the Jackson data.

“Investigators are exploring metabolic derangements, genetic contributions, social determinants of health, patterns of renal function decline, environmental exposures and much more in this remarkable cohort,” she says.

How did you get interested in healthcare disparities research?
During my nephrology fellowship at Johns Hopkins, I was fortunate enough to be mentored by Ebony Boulware, MD, who was then a clinical investigator at Hopkins and is now Chief of the Duke Division of General Internal Medicine. Ebony has an international reputation for kidney disease health disparities research and is a phenomenal mentor and role model. Working with her fueled and continues to fuel my passion for healthcare disparities clinical research. I obtained didactic training in epidemiology during a KL2 clinical research award at Hopkins, and have been doing clinical research ever since. 

What healthcare disparities exist in nephrology?
Racial and ethnic minorities are disproportionately affected by kidney disease and have a three-fold greater incidence of end stage kidney disease compared to whites. African Americans with chronic kidney disease have a two-fold higher risk of death than whites. This high-risk group has been noted to be less likely to see a nephrologist, have higher rates of adverse safety events, and to have less dialysis-preparedness compared to whites.

What contributes to these disparities?
Some are due to increased prevalence of diabetes and hypertension among African Americans, differential levels of health literacy, and variable disease awareness and recognition by both patients and providers. Recent studies have also elucidated a strong genetic predisposition for the development of kidney disease in individuals of African ancestry. But even after controlling for the identified factors shown to contribute to worse outcomes in kidney disease among African Americans, we still cannot completely explain why racial and ethnic minorities with kidney disease fare worse than their white counterparts. 

Tell us about your involvement in the Jackson Heart Study (JHS).
When I returned to Duke in 2014, Ebony and I were both interested in this cohort of African Americans, many of whom have multi-morbidity. Fortunately, Duke serves as a JHS Vanguard Center, which facilitates research and collaboration. Through the Duke JHS kidney disease working group, I’ve been exploring social and psychosocial factors. The JHS compiles comprehensive social science questionnaires that help us understand how things such as moods (e.g. stress) and outlooks (e.g. perceived discrimination) contribute to health outcomes. What we have found thus far is that trust plays a big role in engagement in care among African Americans.

What can the medical community do to increase that trust?
Thinking of individuals as part of a community rather than individual islands is the key to improving trust. Engaging churches, community centers, and sports leagues is a good way to raise awareness and promote engagement among African Americans. Duke has several projects in a variety of disciplines focused on community-based participatory research.

What are your goals for the future?
Promoting engagement in care early in the disease process will be key to improving long term health outcomes. I want to understand how to develop effective early interventions. For example, can increasing kidney disease awareness improve adverse safety events in those at risk of kidney failure? Can using social media promote engagement in kidney disease care by young African Americans? Racial and ethnic minorities are more likely to own a smartphone than whites and are the most active users of the mobile web, so mobile technologies are promising tools.

Final thoughts?
I’d like to emphasize that health disparities research is not the study of health in minority populations. Rather, it is the study of differences in health among various populations. My hope is that in the future, all healthcare providers universally acknowledge that health disparities exist. We cannot apply the same rules of care to all populations, and the more we understand regarding genetic, cultural, and behavioral contributions to health, the more effectively we can target therapies to improve outcomes.