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

Abstract

Background and Objectives: Patterns of end-of-life care among patients with end-stage renal disease (ESRD) differ by race. Whether the magnitude of racial differences in end-of-life care varies across regions is not known. Design, Setting, Participants, and Measurements: Observational cohort study using data from the United States Renal Data System (USRDS) and regional healthcare spending patterns from the Dartmouth Atlas of Healthcare. Cohort included 101,331 black and white patients 18 years and older who initiated chronic dialysis or received kidney transplantation between June 1, 2005 and September 31, 2008 and died before October 1, 2009. We examined 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). Results: In adjusted analyses, the odds ratios for dialysis discontinuation for black vs. white patients ranged from 0.47 (95% confidence interval (CI) 0.43-0.51) in the highest spending quintile to 0.63 (95% CI 0.54-0.74) in the lowest quintile (P for interaction <0.001). Hospice referral ranged from 0.55 (95% CI 0.50-0.60) in the highest spending quintile to 0.82 (95% CI 0.69-0.96) in the lowest quintile (P for interaction <0.001). The association of race with in-hospital death also differed in magnitude across spending quintiles, ranging from 1.21 (95% CI 1.08-1.35) in the 5th quintile to 1.47 (95% CI 1.27-1.71) in the second quintile (P for interaction <0.001). Conclusion: There are pronounced black-white differences in end-of-life outcomes among patients with ESRD that vary substantially across regions of the US.