Substantial differences in treatment for kidney disease in older people

There are substantial regional differences in treatment practices for the care of the elderly with end-stage renal disease (ESRD), including receipt of hospice care and discontinuation of dialysis before death, according to new American research.

In the study, doctors examined the incidence of ESRD and end-of-life care practices among older adults with ESRD across regions with differing intensities of care. The researchers used data from a national ESRD registry to identify a group of 41,420 adults, aged 65 years or older, who started long-term dialysis or received a kidney transplant between 1 June 2005, and 31 May 2006.
The researchers found that among whites, the incidence of ESRD was progressively higher in regions with greater intensity of care and this trend was most pronounced at older ages. “Among blacks, a similar relationship was present only after men reached the age of 80 years or women reached the age of 85 years.
“Patients in regions in the highest compared with lowest quintile of end-of-life intensity of care were less likely to be under the care of a nephrologist before the onset of ESRD and less likely to have a fistula at the time of haemodialysis initiation,” the study’s authors reported. Overall, 51 per cent of patients died within two years of ESRD onset, ranging from 47.1 per cent in regions in the lowest end-of-life expenditure index quintile to 52.6 per cent in regions in the highest quintile.
“Among decedents, dialysis was discontinued prior to death in 44.3 per cent of those living in regions in the lowest end-of-life expenditure index quintile, compared with 22.2 per cent of those living in regions in the highest quintile,” the researchers reported.
“From the lowest to the highest end-of-life expenditure index quintile, the proportion of patients who received hospice care before death ranged from 33.5 per cent to 20.7 per cent, and the proportion who died in the hospital ranged from 50.3 per cent to 67.8 per cent.”
The authors added that these pronounced regional differences in practice were not explained by differences in patient characteristics measured at the onset of ESRD.
“There is substantial, unexplained regional variation in the care of older adults with ESRD, both prior to ESRD onset and prior to death. This finding underlines the importance of a comprehensive informed and ongoing consent process for ESRD treatment based on available evidence and clinical practice guidelines,” the authors concluded.
JAMA 2010;304:180-186