Geographic variation in black-white differences in end-of-life care for patients with ESRD.

Thomas BA, Rodriguez RA, Boyko EJ, Robinson-Cohen C, Fitzpatrick AL, O'Hare AM
Clin J Am Soc Nephrol. 2013 8 (7): 1171-8

PMID: 23580783 · PMCID: PMC3700690 · DOI:10.2215/CJN.06780712

BACKGROUND AND OBJECTIVES - Patterns of end-of-life care among patients with ESRD differ by race. Whether the magnitude of racial differences in end-of-life care varies across regions is not known.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS - This observational cohort study used data from the US Renal Data System and regional health care spending patterns from the Dartmouth Atlas of Healthcare. The cohort included 101,331 black and white patients 18 years and older who initiated chronic dialysis or received a kidney transplant between June 1, 2005, and September 31, 2008, and died before October 1, 2009. Black-white differences in the odds of in-hospital death, dialysis discontinuation, and hospice referral by quintile of end-of-life expenditure index (EOL-EI) were examined.

RESULTS - In adjusted analyses, the odds ratios for dialysis discontinuation for black versus white patients ranged from 0.47 (95% confidence interval=0.43 to 0.51) in the highest quintile of EOL-EI to 0.63 (95% confidence interval=0.54 to 0.74) in the lowest quintile (P for interaction<0.001). Hospice referral ranged from 0.55 (95% confidence interval=0.50 to 0.60) in the highest quintile of EOL-EI to 0.82 (95% confidence interval=0.69 to 0.96) in the lowest quintile (P for interaction<0.001). The association of race with in-hospital death also differed in magnitude across quintiles of EOL-EI, ranging from 1.21 (95% confidence interval=1.08 to 1.35) in the highest quintile of EOL-EI to 1.47 (95% confidence interval=1.27 to 1.71) in the second quintile (P for interaction<0.001).

CONCLUSIONS - There are pronounced black-white differences in patterns of hospice referral and dialysis discontinuation among patients with ESRD that vary substantially across regions of the United States.

MeSH Terms (26)

African Americans Aged Cohort Studies Dialysis European Continental Ancestry Group Female Healthcare Disparities Health Services Accessibility Hospice Care Hospital Mortality Humans Kidney Failure, Chronic Logistic Models Male Middle Aged Multivariate Analysis Odds Ratio Practice Patterns, Physicians' Referral and Consultation Registries Residence Characteristics Risk Assessment Risk Factors Terminal Care United States Withholding Treatment

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