Regional variation in health care intensity and treatment practices for end-stage renal disease in older adults

Abstract

Context: An increasing number of older adults are being treated for end-stage renal disease (ESRD) with long-term dialysis.

Objectives: To determine how ESRD treatment practices for older adults vary across regions with differing end-of-life intensity of care.

Design, setting, and participants: Retrospective observational study using a national ESRD registry to identify a cohort of 41,420 adults (of white or black race), aged 65 years or older, who started long-term dialysis or received a kidney transplant between June 1, 2005, and May 31, 2006. Regional end-of-life intensity of care was defined using an index from the Dartmouth Atlas of Healthcare.

Main outcome measures: Incidence of treated ESRD (dialysis or transplant), preparedness for ESRD (under the care of a nephrologist, having a fistula [vs graft or catheter] at time of hemodialysis initiation), and end-of-life care practices.

Results: Among whites, the incidence of ESRD was progressively higher in regions with greater intensity of care and this trend was most pronounced at older ages. Among blacks, a similar relationship was present only at advanced ages (men aged > or = 80 years and women aged > or = 85 years). Patients living in regions in the highest compared with lowest quintile of end-of-life intensity of care were less likely to be under the care of a nephrologist before the onset of ESRD (62.3% [95% confidence interval {CI}, 61.3%-63.3%] vs 71.1% [95% CI, 69.9%-72.2%], respectively) and less likely to have a fistula (vs graft or catheter) at the time of hemodialysis initiation (11.2% [95% CI, 10.6%-11.8%] vs 16.9% [95% CI, 15.9%-17.8%]). Among patients who died within 2 years of ESRD onset (n = 21,190), those living in regions in the highest compared with lowest quintile of end-of-life intensity of care were less likely to have discontinued dialysis before death (22.2% [95% CI, 21.1%-23.4%] vs 44.3% [95% CI, 42.5%-46.1%], respectively), less likely to have received hospice care (20.7% [95% CI, 19.5%-21.9%] vs 33.5% [95% CI, 31.7%-35.4%]), and more likely to have died in the hospital (67.8% [95% CI, 66.5%-69.1%] vs 50.3% [95% CI, 48.5%-52.1%]). These differences persisted in adjusted analyses.

Conclusion: There are pronounced regional differences in treatment practices for ESRD in older adults that are not explained by differences in patient characteristics.

Figure 1

Incidence of Treated End-stage Renal Disease (ESRD) by Age, Race, Sex, and End-of-Life Expenditure Index Quintile Error bars represent 95% confidence intervals. ^aThe first is the lowest end-of-life expenditure index quintile and the fifth is the highest quintile.

Figure 2

ESRD Incidence Rate Ratios for the Highest Compared With the Lowest End-of-Life Expenditure Index Quintile by Age, Race, and Sex ESRD indicates end-stage renal disease.

Figure 3

Discontinuation of Dialysis Before Death by Age, Race, and End-of-Life Expenditure Index Quintile Error bars represent 95% confidence intervals. ^aThe first is the lowest end-of-life expenditure index quintile and the fifth is the highest quintile.