title: Geographic variation in black-white differences in end-of-life care for patients with ESRD.
abstract: OBJECTIVE
  Patterns of end-of-life care among patients with ESRD differ by race. Whether the magnitude of racial differences in end-of-life care varies across regions is not known.
  
  
  METHODS
  This observational cohort study used data from the US Renal Data System and regional health care spending patterns from the Dartmouth Atlas of Healthcare. The cohort included 101,331 black and white patients 18 years and older who initiated chronic dialysis or received a kidney transplant between June 1, 2005, and September 31, 2008, and died before October 1, 2009. Black-white differences in the odds of in-hospital death, dialysis discontinuation, and hospice referral by quintile of end-of-life expenditure index (EOL-EI) were examined.
  
  
  RESULTS
  In adjusted analyses, the odds ratios for dialysis discontinuation for black versus white patients ranged from 0.47 (95% confidence interval=0.43 to 0.51) in the highest quintile of EOL-EI to 0.63 (95% confidence interval=0.54 to 0.74) in the lowest quintile (P for interaction<0.001). Hospice referral ranged from 0.55 (95% confidence interval=0.50 to 0.60) in the highest quintile of EOL-EI to 0.82 (95% confidence interval=0.69 to 0.96) in the lowest quintile (P for interaction<0.001). The association of race with in-hospital death also differed in magnitude across quintiles of EOL-EI, ranging from 1.21 (95% confidence interval=1.08 to 1.35) in the highest quintile of EOL-EI to 1.47 (95% confidence interval=1.27 to 1.71) in the second quintile (P for interaction<0.001).
  
  
  CONCLUSIONS
  There are pronounced black-white differences in patterns of hospice referral and dialysis discontinuation among patients with ESRD that vary substantially across regions of the United States.
authors.affiliation: Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington 98195, USA. bthomas19@gmail.com
authors.forename: Bernadette A
authors.initials: BA
authors.lastname: Thomas
authors.forename: Rudolph A
authors.initials: RA
authors.lastname: Rodriguez
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Boyko
authors.forename: Cassianne
authors.initials: C
authors.lastname: Robinson-Cohen
authors.forename: Annette L
authors.initials: AL
authors.lastname: Fitzpatrick
authors.forename: Ann M
authors.initials: AM
authors.lastname: O'Hare
mesh_terms: D001741:Black or African American / Q000706:statistics & numerical data; D000368:Aged; D015331:Cohort Studies; D003956:Dialysis; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D054625:Healthcare Disparities / Q000208:ethnology* / Q000706:statistics & numerical data; D017051:Hospice Care; D017052:Hospital Mortality / Q000208:ethnology; D006801:Humans; D007676:Kidney Failure, Chronic / Q000208:ethnology / Q000401:mortality / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D012017:Referral and Consultation; D012042:Registries; D012111:Residence Characteristics / Q000706:statistics & numerical data; D018570:Risk Assessment; D012307:Risk Factors; D013727:Terminal Care / Q000706:statistics & numerical data; D014481:United States / Q000453:epidemiology; D044465:White People / Q000706:statistics & numerical data; D028761:Withholding Treatment