End-stage Renal Disease: Racial Disparities Vary by Region

Substantial racial disparities exist in end-of-life care patterns for patients with end-stage renal disease (ESRD), varying by geographic region, according to a study published online April 11 in the Clinical Journal of the American Society of Nephrology.

Bernadette A. Thomas, MD, from the Division of Nephrology, Department of Medicine, University of Washington, Seattle, and colleagues conducted an observational cohort study using data from the US Renal Data System and Dartmouth Atlas of Healthcare.

The analysis covered 101,331 black and white patients at least 18 years old who started dialysis or received a kidney transplant between June 1, 2005, and September 31, 2008, and who died before October 1, 2009. The researchers compared black and white differences in odds of dialysis discontinuation, hospice referral, and in-hospital death by quintile of end-of-life expenditure index.

Black patients in the study were younger, included a higher percentage of women, and had higher prevalence of diabetes and stroke but lower prevalence of congestive heart failure, coronary and pulmonary diseases, and cancer compared with white patients in the study. A higher percentage of the white patients included died within 6 months of ESRD onset (37.1% vs 33.8%). The percentage of blacks by quintile ranged from 7.6% to 30.6%, lowest to highest.

In adjusted analyses stratified by race and geographic region, the researchers found that black patients were less likely than whites to have dialysis discontinued (highest quintile: odds ratio [OR], 0.47 [95% confidence interval (CI), 0.43 - 0.51]; lowest quintile: OR, 0.63 [95% CI, 0.54 - 0.74]; P < .001) and less likely be referred to hospice care (highest quintile: OR, 0.55 [95% CI, 0.50 - 0.60]; lowest quintile: OR, 0.82 [95% CI, 0.69 - 0.96]; P < .001), but were more likely to die in a hospital (highest quintile: OR, 1.21 [95% CI, 1.08 -1.35]; second quintile: OR, 1.47 [95% CI, 1.27 - 1.71]; P < .001).

To determine ORs, the researchers adjusted for age, sex, body mass index, estimated glomerular filtration rate, and comorbidities including coronary disease, diabetes, stroke, and cancer, as well as type of vascular access at onset of ESRD. They also adjusted for other factors including ability to walk, treatment modality, prior nephrology care, and cause of death.

"In all quintiles of [the end-of-life expenditure index], black patients were more likely than white patients to have died in the hospital and less likely to have discontinued dialysis and to have been referred to hospice," the researchers write.

They caution, however, that regional differences patterns of care may not translate into differences in quality of care without further study into patient preferences and values. In addition, among the study limitations was the inability to fully account for socioeconomic, cultural, and family variables.

"In conclusion," the researchers write, "there is substantial regional variation in the magnitude of racial differences in patterns of end-of-life care among adults with ESRD. Black–white differences in dialysis discontinuation and hospice referral were most pronounced in those regions with the highest levels of end-of-life Medicare spending. Efforts are needed to understand the underlying reasons for these differences and the extent to which these differences reflect differences in patient values, goals, and preferences."

This research was supported by a Ruth L. Kirschstein National Research Award from the National Institutes of Health and a Beeson Career Development Award from the National Institute on Aging. The authors have disclosed no relevant financial relationships.

Clin J Am Soc Nephrol. Published online April 11, 2013. Abstract