title: Regional variation in health care intensity and treatment practices for end-stage renal disease in older adults.
abstract: BACKGROUND
  An increasing number of older adults are being treated for end-stage renal disease (ESRD) with long-term dialysis.
  
  
  OBJECTIVE
  To determine how ESRD treatment practices for older adults vary across regions with differing end-of-life intensity of care.
  
  
  METHODS
  Retrospective observational study using a national ESRD registry to identify a cohort of 41,420 adults (of white or black race), aged 65 years or older, who started long-term dialysis or received a kidney transplant between June 1, 2005, and May 31, 2006. Regional end-of-life intensity of care was defined using an index from the Dartmouth Atlas of Healthcare.
  
  
  METHODS
  Incidence of treated ESRD (dialysis or transplant), preparedness for ESRD (under the care of a nephrologist, having a fistula [vs graft or catheter] at time of hemodialysis initiation), and end-of-life care practices.
  
  
  RESULTS
  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 at advanced ages (men aged > or = 80 years and women aged > or = 85 years). Patients living 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 (62.3% [95% confidence interval {CI}, 61.3%-63.3%] vs 71.1% [95% CI, 69.9%-72.2%], respectively) and less likely to have a fistula (vs graft or catheter) at the time of hemodialysis initiation (11.2% [95% CI, 10.6%-11.8%] vs 16.9% [95% CI, 15.9%-17.8%]). Among patients who died within 2 years of ESRD onset (n = 21,190), those living in regions in the highest compared with lowest quintile of end-of-life intensity of care were less likely to have discontinued dialysis before death (22.2% [95% CI, 21.1%-23.4%] vs 44.3% [95% CI, 42.5%-46.1%], respectively), less likely to have received hospice care (20.7% [95% CI, 19.5%-21.9%] vs 33.5% [95% CI, 31.7%-35.4%]), and more likely to have died in the hospital (67.8% [95% CI, 66.5%-69.1%] vs 50.3% [95% CI, 48.5%-52.1%]). These differences persisted in adjusted analyses.
  
  
  CONCLUSIONS
  There are pronounced regional differences in treatment practices for ESRD in older adults that are not explained by differences in patient characteristics.
authors.affiliation: Department of Medicine, University of Washington, and VA Puget Sound Healthcare System, Seattle, WA 98108, USA. Ann.OHare@va.gov
authors.forename: Ann M
authors.initials: AM
authors.lastname: O'Hare
authors.forename: Rudolph A
authors.initials: RA
authors.lastname: Rodriguez
authors.forename: Susan M
authors.initials: SM
authors.lastname: Hailpern
authors.forename: Eric B
authors.initials: EB
authors.lastname: Larson
authors.forename: Manjula
authors.initials: M
authors.lastname: Kurella Tamura
mesh_terms: D000368:Aged; D044383:Black People; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000208:ethnology / Q000628:therapy*; D016030:Kidney Transplantation / Q000706:statistics & numerical data*; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012042:Registries / Q000706:statistics & numerical data; D006435:Renal Dialysis / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013727:Terminal Care / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology; D044465:White People; D001741:Black or African American