Expanded Prospective Payment System and Use of and Outcomes with Home Dialysis by Race and Ethnicity in the United States

Abstract

Background and objectives: We investigated whether the recent growth in home dialysis use was proportional among all racial/ethnic groups and also whether there were changes in racial/ethnic differences in home dialysis outcomes.

Design, setting, participants, & measurements: This observational cohort study of US Renal Data System patients initiating dialysis from 2005 to 2013 used logistic regression to estimate racial/ethnic differences in home dialysis initiation over time, and used competing risk models to assess temporal changes in racial/ethnic differences in home dialysis outcomes, specifically: (1) transfer to in-center hemodialysis (HD), (2) mortality, and (3) transplantation.

Results: Of the 523,526 patients initiating dialysis from 2005 to 2013, 55% were white, 28% black, 13% Hispanic, and 4% Asian. In the earliest era (2005-2007), 8.0% of white patients initiated dialysis with home modalities, as did a similar proportion of Asians (9.2%; adjusted odds ratio [aOR], 0.95; 95% confidence interval [95% CI], 0.86 to 1.05), whereas lower proportions of black [5.2%; aOR, 0.71; 95% CI, 0.66 to 0.76] and Hispanic (5.7%; aOR, 0.83; 95% CI, 0.86 to 0.93) patients did so. Over time, home dialysis use increased in all groups and racial/ethnic differences decreased (2011-2013: 10.6% of whites, 8.3% of blacks [aOR, 0.81; 95% CI, 0.77 to 0.85], 9.6% of Hispanics [aOR, 0.94; 95% CI, 0.86 to 1.00], 14.2% of Asians [aOR, 1.04; 95% CI, 0.86 to 1.12]). Compared with white patients, the risk of transferring to in-center HD was higher in blacks, similar in Hispanics, and lower in Asians; these differences remained stable over time. The mortality rate was lower for minority patients than for white patients; this difference increased over time. Transplantation rates were lower for blacks and similar for Hispanics and Asians; over time, the difference in transplantation rates between blacks and Hispanics versus whites increased.

Conclusions: From 2005 to 2013, as home dialysis use increased, racial/ethnic differences in initiating home dialysis narrowed, without worsening rates of death or transfer to in-center HD in minority patients, as compared with white patients.

Keywords: Asian Continental Ancestry Group; Cohort Studies; Ethnic Groups; European Continental Ancestry Group; Hemodialysis, Home; Hispanic Americans; Logistic Models; Odds Ratio; Prospective Payment System; disparities; ethnicity; home dialysis; modality selection; outcomes; peritoneal dialysis; race; renal dialysis; technique failure; temporal trends.

Graphical abstract

Figure 1.

Home dialysis initiation increased in every racial/ethnic group over time.

Figure 2.

Racial/ethnic differences in initiation of dialysis with home dialysis decreased over time. Odds ratios of initiating dialysis with home modalities (versus in-center hemodialysis) in minority patients (versus white patients), by era. (A) Overall results. P values for comparisons between first versus last era: P<0.001 for unadjusted and adjusted black and Hispanic models; P=0.002 for unadjusted and P=0.02 for adjusted Asian models. (B) Adjusted results, by Medicare status. P=0.54 for interaction term between Medicare status, era, and race/ethnicity. Adjusted models included: individual level: age, sex, comorbidities, body mass index, laboratory values, predialysis nephrologist care, insurance, employment; neighborhood level: poverty, education level, racial/ethnic composition, linguistic isolation, number of home dialysis units and nephrologists, Census Division, urban/rural; profit status of facility. 95% CI, 95% confidence interval.

Figure 3.

Temporal changes in racial/ethnic differences in clinical outcomes among patients on home dialysis varied depending on the outcome. Hazard ratios and 95% confidence intervals of outcomes in minority patients versus white patients, by era. (A) Association between race/ethnicity and transfer to in-center hemodialysis (ICHD). P>0.05 for all models. (B) Association between race/ethnicity and mortality. P=0.07 for unadjusted and P=0.01 for adjusted black models; P=0.002 for unadjusted and adjusted Hispanic models; P=0.06 for unadjusted and P=0.01 for adjusted Asian models. (C) Association between race/ethnicity and kidney transplantation. P<0.001 for unadjusted and adjusted black models; P=0.01 for unadjusted and adjusted Hispanic models; P>0.05 for unadjusted and adjusted Asian models. All P values are comparisons between the hazard ratio in the first versus last era for the specified minority group versus whites. Adjusted models included: individual level: age, sex, comorbidities, body mass index, laboratory values, predialysis nephrologist care, insurance, employment; neighborhood level: poverty, education level, racial/ethnic composition, linguistic isolation, number of home dialysis units and nephrologists, Census Division, urban/rural; profit status of facility. 95% CI, 95% confidence interval.