Regional variation in care at the end of life: discontinuation of dialysis

Charles E Gessert,Irina V Haller,Brian P Johnson

doi:10.1186/1471-2318-13-39

Abstract

BackgroundRegional variation in the intensity of end-of-life care contributes significantly to the overall cost of health care. The interpretation of patterns of regional variation hinges, in part, on appropriate adjustment for regional variation in demographic variables such as age, race, sex, and rural vs. urban residence. This study examined regional variation in discontinuation of dialysis prior to death in the US, after adjustment for key demographic variables.MethodsIn this retrospective cohort study of the 2009 United States Renal Data System (USRDS) database we examined discontinuation of dialysis prior to death among deceased adult patients with end-stage renal disease (ESRD) from the 50 states and the District of Columbia. The discontinuation of dialysis prior to death was ascertained from the Centers for Medicare & Medicaid Services form 2746 (ESRD Death Notification form). We used logistic regression to estimate the log-odds of discontinuation of dialysis with ESRD network as independent variable adjusted for urban–rural status, demographic and treatment variables.ResultsThe study cohort included 715,605 deceased ESRD patients; for 176,021 of whom (24.6%) dialysis was discontinued prior to death. Dialysis was discontinued at higher rates for women than for men (26.3% vs. 23.0%, p < 0.001) and for whites than for blacks (29.5% vs. 14.7%, p < 0.001). Significant regional variation in dialysis discontinuation prior to death was noted after adjustment for age, race and rural–urban status: rates of discontinuation in the Upper Midwest and Mountain regions were more than double the rates in Southern and Coastal regions. This pattern parallels the regional pattern of end-of-life health service utilization documented in the Dartmouth Atlas and other studies.ConclusionsDiscontinuation of dialysis prior to death was common in the US between 1995 and 2009. The deaths of nearly one quarter of chronic dialysis patients followed a decision to discontinue dialysis. Significant regional variation in discontinuation rates exists after adjusting for age, race, sex, and rural–urban status. Further research and analysis is needed on the cultural and economic factors that affect regional variation in health services utilization, especially in regard to the use of expensive medical services near the end of life.

Highlights

Regional variation in the intensity of end-of-life care contributes significantly to the overall cost of health care
The Dartmouth Atlas of Health Care documented substantial regional differences in the use of inpatient care, intensive care, physicians’ visits, and other services at the end of life, and concluded that “...to the extent that end of life issues are addressed in practice, they are resolved in ways that depend on where the patient happens to live, not on the patient’s preferences or the power to extend life” [13]
An end-stage renal disease (ESRD) patient is a person with chronic renal failure who requires renal replacement treatment that has been certified by a physician at onset of ESRD, or when other evidence of chronic dialysis or a kidney transplant exists

Summary

Introduction

Regional variation in the intensity of end-of-life care contributes significantly to the overall cost of health care. Regional variation in end-of-life care is of special interest, both because of the substantial Medicare expenditures in the last year of life [6,7,8,9], and because of concerns about overuse of services that may be both burdensome and offer little benefit to dying patients [10]. Significant regional variation has been documented in the use of feeding tubes [10,11], hospitalizations late in life [10], intensive care use in the last month of life [10], and other services and conditions [12] as well as in overall expenditures on end-of-life care [5,6]. Many medical services – such as hospitalizations and consultations with specialists – are used more at the end of life in areas of the South and along the urban corridors on the East and West Coasts, when compared with use in Midwestern and Mountain regions [12]

Methods

Results

Discussion

Conclusion