title: Risk Adjustment and the Assessment of Disparities in Dialysis Mortality Outcomes.
abstract: Standardized mortality ratios (SMRs) reported by Medicare compare mortality at individual dialysis facilities with the national average, and are currently adjusted for race. However, whether the adjustment for race obscures or clarifies disparities in quality of care for minority groups is unknown. Cox model-based SMRs were computed with and without adjustment for patient race for 5920 facilities in the United States during 2010. The study population included virtually all patients treated with dialysis during this period. Without race adjustment, facilities with higher proportions of black patients had better survival outcomes; facilities with the highest percentage of black patients (top 10%) had overall mortality rates approximately 7% lower than expected. After adjusting for within-facility racial differences, facilities with higher proportions of black patients had poorer survival outcomes among black and non-black patients; facilities with the highest percentage of black patients (top 10%) had mortality rates approximately 6% worse than expected. In conclusion, accounting for within-facility racial differences in the computation of SMR helps to clarify disparities in quality of health care among patients with ESRD. The adjustment that accommodates within-facility comparisons is key, because it could also clarify relationships between patient characteristics and health care provider outcomes in other settings.
authors.affiliation: Kidney Epidemiology and Cost Center, Department of Biostatistics, and.
authors.forename: John
authors.initials: J
authors.lastname: Kalbfleisch
authors.affiliation: Department of Biostatistics, and.
authors.forename: Robert
authors.initials: R
authors.lastname: Wolfe
authors.affiliation: Kidney Epidemiology and Cost Center, Department of Biostatistics, and.
authors.forename: Sarah
authors.initials: S
authors.lastname: Bell
authors.affiliation: Kidney Epidemiology and Cost Center.
authors.forename: Rena
authors.initials: R
authors.lastname: Sun
authors.affiliation: Kidney Epidemiology and Cost Center, Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; and.
authors.forename: Joseph
authors.initials: J
authors.lastname: Messana
authors.affiliation: Kidney Epidemiology and Cost Center, Department of Biostatistics, and.
authors.forename: Tempie
authors.initials: T
authors.lastname: Shearon
authors.affiliation: Kidney Epidemiology and Cost Center, Department of Biostatistics, and.
authors.forename: Valarie
authors.initials: V
authors.lastname: Ashby
authors.affiliation: Kidney Epidemiology and Cost Center, Department of Biostatistics, and.
authors.forename: Robin
authors.initials: R
authors.lastname: Padilla
authors.affiliation: Kidney Epidemiology and Cost Center, Department of Biostatistics, and.
authors.forename: Min
authors.initials: M
authors.lastname: Zhang
authors.affiliation: Arbor Research Collaborative for Health, Ann Arbor, Michigan.
authors.forename: Marc
authors.initials: M
authors.lastname: Turenne
authors.affiliation: Arbor Research Collaborative for Health, Ann Arbor, Michigan.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Pearson
authors.affiliation: Kidney Epidemiology and Cost Center, Department of Biostatistics, and.
authors.forename: Claudia
authors.initials: C
authors.lastname: Dahlerus
authors.affiliation: Kidney Epidemiology and Cost Center, Department of Biostatistics, and yili@umich.edu.
authors.forename: Yi
authors.initials: Y
authors.lastname: Li
mesh_terms: D000293:Adolescent; D000328:Adult; D001741:Black or African American; D000368:Aged; D000465:Algorithms; D044383:Black People; D005006:Ethnicity; D005260:Female; D054624:Health Status Disparities; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000208:ethnology / Q000401:mortality* / Q000628:therapy*; D008297:Male; D006278:Medicare; D008875:Middle Aged; D016016:Proportional Hazards Models; D011787:Quality of Health Care; D006435:Renal Dialysis / Q000706:statistics & numerical data*; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome; D014481:United States; D044465:White People; D055815:Young Adult
keywords: dialysis; end-stage renal disease; mortality; outcomes; risk factors