Trends in Receipt of Intensive Procedures at the End of Life Among Patients Treated With Maintenance Dialysis.
BACKGROUND
Many dialysis patients receive intensive procedures intended to prolong life at the very end of life. However, little is known about trends over time in the use of these procedures. We describe temporal trends in receipt of inpatient intensive procedures during the last 6 months of life among patients treated with maintenance dialysis.


METHODS
Mortality follow-back study.


METHODS
649,607 adult Medicare beneficiaries on maintenance dialysis therapy who died in 2000 to 2012.


METHODS
Period of death (2000-2003, 2004-2008, or 2009-2012), age at time of death (18-59, 60-64, 65-69, 70-74, 75-79, 80-84, and ≥85 years), and race/ethnicity (Hispanic, non-Hispanic black, or non-Hispanic white).


RESULTS
Receipt of an inpatient intensive procedure (defined as invasive mechanical ventilation/intubation, tracheostomy, gastrostomy/jejunostomy tube insertion, enteral or parenteral nutrition, or cardiopulmonary resuscitation) during the last 6 months of life.


RESULTS
Overall, 34% of cohort patients received an intensive procedure in the last 6 months of life, increasing from 29% in 2000 to 36% in 2012 (with 2000-2003 as the referent category; adjusted risk ratios [RRs] were 1.06 [95% CI, 1.05-1.07] and 1.10 [95% CI, 1.09-1.12] for 2004-2008 and 2009-2012, respectively). Use of intensive procedures increased more markedly over time in younger versus older patients (comparing 2009-2012 to 2000-2003, adjusted RR was 1.18 [95% CI, 1.15-1.20] for the youngest age group as opposed to 1.00 [95% CI, 0.96-1.04] for the oldest group). Comparing 2009 to 2012 to 2000 to 2003, the use of intensive procedures increased more dramatically for Hispanic patients than for non-Hispanic black or non-Hispanic white patients (adjusted RRs of 1.18 [95% CI, 1.14-1.22], 1.09 [95% CI, 1.07-1.11], and 1.10 [95% CI, 1.08-1.12], respectively).


CONCLUSIONS
Data sources do not provide insight into reasons for observed trends in the use of intensive procedures.


CONCLUSIONS
Among patients treated with maintenance dialysis, there is a trend toward more frequent use of intensive procedures at the end of life, especially in younger patients and those of Hispanic ethnicity.
Division of Nephrology, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA. Electronic address: aeneanya@partners.org.
Nwamaka D
ND
Eneanya
Division of Nephrology and Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA.
Susan M
SM
Hailpern
Division of Nephrology and Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA; Hospital and Specialty Medicine, Veteran Affairs Puget Sound Health Care System, Seattle, WA; Group Health Research Institute, Seattle, WA.
Ann M
AM
O'Hare
Geriatric Research and Education Clinical Center, Veteran Affairs Palo Alto Health Care System, Palo Alto, CA.
Manjula
M
Kurella Tamura
Division of Nephrology and Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA.
Ronit
R
Katz
Division of Nephrology and Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA.
William
W
Kreuter
Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA.
Maria E
ME
Montez-Rath
Seattle-Denver Center of Innovation, Veterans Affairs Puget Sound Healthcare System, Seattle, WA.
Paul L
PL
Hebert
Division of Nephrology and Kidney Research Institute, Department of Medicine, University of Washington, Seattle, WA.
Yoshio N
YN
Hall
D000293:Adolescent; D000328:Adult; D001741:Black or African American; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006630:Hispanic or Latino; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis; D013727:Terminal Care / Q000379:methods / Q000706:statistics & numerical data / Q000639:trends*; D013997:Time Factors; D044465:White People; D055815:Young Adult
End-of-life; Hispanic; Medicare spending; age differences; dialysis; elderly; end-stage renal disease (ESRD); ethnic disparities; health care costs; hospitalization; intensive procedures; mortality follow-back
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