Regional variations in kidney care raise questions about spending, says Stanford nephrologist

Jul 13, 2010

The type and intensity of treatment older Americans receive for kidney failure depends on the region where they receive care rather than on evidence-based practice guidelines and patient preferences, according to a study to be published in the July 14 Journal of the American Medical Association.

There are pronounced regional differences in treatment practices for with , including decisions about starting or stopping , that don't seem to be explained by differences in patient characteristics, said Manjula Kurella Tamura, MD, senior author of the study and assistant professor of nephrology at the Stanford University School of Medicine.

"Our data seem to suggest that at present these important decisions are heavily influenced by where patients live," added lead author Ann O'Hare, MD, associate professor of nephrology at the University of Washington in Seattle, where the study was conducted.

To examine geographic variations in health-care delivery among older patients with kidney failure, researchers used a registry to identify patients age 65 or older who started dialysis between 2005 and 2006. They then grouped the patients into geographic regions based on the average level of health-care spending in that region at the end of life. The ranking of geographic regions according to health-care spending, or intensity of care, at the end of life comes from the Dartmouth Atlas of Healthcare.

In regions with high-intensity end-of-life care, the study found a higher density of nephrologists — physicians specializing in — and higher rates of kidney failure treated with chronic dialysis, especially among the very elderly. Despite a higher density of nephrologists in high-intensity regions, patients with kidney failure were less likely to have seen a nephrologist before starting dialysis.

What's more, said Kurella Tamura, "People who live in these high-spending areas don't tend to fare any better than the low-spending areas."

Among patients who died, they also found that patients who lived in high-intensity regions were more likely to die in the hospital and less likely to have used hospice care.

"The regional differences were most pronounced for very elderly patients age 85 and over, a group for whom the benefits of dialysis are least certain," said O'Hare.

"Although our study wasn't designed to identify the reasons for these variations, the patterns we observed are consistent with previous studies examining geographic variations in treatment practices for other conditions. The findings seem to suggest that higher-spending regions have a more interventional, aggressive style of practice at the end of life," Kurella Tamura said.

As the federal government has enacted health-care reform over the last two years, there has been much debate about the size and nature of regional variations in health-care spending, particularly for a variety of treatments at the end of life. The outcome of this debate could affect the nation's ability to rein in spiraling medical costs: If some regions are truly practicing medicine in a more cost-effective manner — without compromising quality — it means that savings could be achieved by other regions adopting those best practices.

This was one of the motivating factors for conducting the study, Kurella Tamura said.

"Treatment practices tend to vary the most around interventions that are of uncertain benefit. Chronic dialysis is expensive and invasive, and the benefits of are least certain in the elderly. So Dr. O'Hare and I wondered whether treatment practices for kidney failure varied in this way also," Kurella Tamura said.

Apparently, they do.

Americans over the age of 80 are the fastest-growing segment of population to start dialysis, which costs Medicare about $100,000 the first year. Within the United States, 400,000 patients receive dialysis treatments. Most commonly, dialysis treatments involve periodically circulating a patient's blood through an artificial kidney machine as a way to remove waste products from the blood when the kidneys fail. Patients have to travel to and from dialysis centers for their treatments, typically three times a week for three to four hours per treatment.

The decision of when to start and stop receiving dialysis can be a difficult one, researchers said, and highlights a need for better training of kidney specialists and other health-care professionals in end-of-life care and support from their colleagues in geriatric and palliative care.

"We need to get serious about optimizing end-of-life care," Kurella Tamura said. "We need to make sure all patients are getting care that matches their preferences and values rather than care that is simply a reflection of where they live."

Explore further: Vietnam battles fatal measles outbreak

add to favorites email to friend print save as pdf

Related Stories

Before starting dialysis, patients need nephrologist care

Mar 25, 2009

For patients with end-stage renal disease (ESRD), receiving care from a nephrologist in the months before starting dialysis reduces the risk of death during the first year on dialysis, reports a study in the May 2009 issue ...

End of life care falls short for kidney disease patients

Jan 15, 2010

Patients with advanced chronic kidney disease (CKD) often do not receive adequate end-of-life care and are unhappy with the medical decisions made as their conditions worsen, according to a study appearing in an upcoming ...

Recommended for you

US orders farms to report pig virus infections

15 hours ago

The U.S. government is starting a new program to help monitor and possibly control the spread of a virus that has killed millions of pigs since showing up in the country last year.

Foreigner dies of MERS in Saudi

16 hours ago

A foreigner has died after she contracted MERS in the Saudi capital, the health ministry said on announced Friday, bringing the nationwide death toll to 73.

Vietnam battles fatal measles outbreak

19 hours ago

Vietnam is scrambling to contain a deadly outbreak of measles that has killed more than 100 people, mostly young children, and infected thousands more this year, the government said Friday.

New clues on tissue scarring in scleroderma

20 hours ago

A discovery by Northwestern Medicine scientists could lead to potential new treatments for breaking the cycle of tissue scarring in people with scleroderma.

User comments : 0

More news stories

Treating depression in Parkinson's patients

A group of scientists from the University of Kentucky College of Medicine and the Sanders-Brown Center on Aging has found interesting new information in a study on depression and neuropsychological function in Parkinson's ...

Health care site flagged in Heartbleed review

People with accounts on the enrollment website for President Barack Obama's signature health care law are being told to change their passwords following an administration-wide review of the government's vulnerability to the ...

Airbnb rental site raises $450 mn

Online lodging listings website Airbnb inked a $450 million funding deal with investors led by TPG, a source close to the matter said Friday.