Racial disparities exist in end-of-life care for US dialysis patients

At the end of life, black patients with kidney failure receiving chronic dialysis are less likely to be referred to hospice and to discontinue dialysis compared with white patients, according to a study appearing in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN). Racial differences in care are especially pronounced in parts of the country that spend the most on end-of-life care. Efforts are needed to better understand why there are such large racial differences in end-of-life care and to ensure that such care reflects dialysis patients' goals and preferences.

There are known racial differences in aspects of kidney health such as access to kidney transplantation and pre-dialysis kidney care, and health and survival during kidney disease and after kidney transplantation. Racial differences in patterns of end-of-life care have generally received much less attention, although studies indicate that black patients with kidney failure are less likely to be referred to hospice, less likely to discontinue dialysis, and more likely to receive intensive interventions such as ICU admission at the very end of life.

Most prior studies describing racial differences in patterns of end-of-life care have not examined whether the magnitude of these differences is uniform across different regions of the country. To investigate, Bernadette Thomas, MD (University of Washington, in Seattle) and her colleagues examined data from the United States Renal Data System on 101,331 black and white adult patients who initiated chronic dialysis or received a kidney transplant between 2005 and 2008 and died before October 1, 2009. The investigators also analyzed regional healthcare spending patterns from the Dartmouth Atlas of Healthcare.

Similar to other studies, the researchers found that there were large racial differences in rates of hospice referral and dialysis discontinuation. However, when black and white patients were examined separately, the investigators also observed large differences in the frequency of hospice referral and dialysis discontinuation between high and low spending regions. "Although large racial differences in dialysis discontinuation and hospice referral were present in all regions, these differences were most pronounced in the highest spending regions," said Dr. Thomas.