Racial and Ethnic Differences in End-of-Life Care for Patients with End-Stage Renal Disease

Pham C, Braun UK. Racial and Ethnic Differences in End-of-Life Care for Patients with End-Stage Renal Disease. [Abstract]. Journal of pain and symptom management. 2009 Mar 1; 37(3):556-557.

Related HSR&D Project(s)

• IIR 02-224 – A Culturally Sensitive Values-Guided Aid for End of Life Decision-Making

Objective 1. Discuss the differences in care by race/ethnicity for patients with end-stage renal disease. I. Background. Patients with end-stage renal disease are known to have different rates of receiving kidney transplants by race/ethnicity. No national data exist regarding racial/ethnic differences for patients with end-stage renal disease in the use of common life-sustaining interventions often given at the end of life. II. Research Objectives. To determine whether among veterans with end-stage renal disease the use of common life-sustaining treatments differed significantly by race/ethnicity. III. Methods. Design. Retrospective cohort study during fiscal years 1991-2007. Patients. Hospitalized veterans age 55 years or older with end-stage renal disease, on hemodialysis or peritoneal dialysis, identified by ICD-9 codes and CPT codes. Measurements. Utilization patterns by race/ ethnicity for five life-sustaining therapies. Logistic regression models evaluated differences among Caucasians, African Americans, and Hispanics, controlling for age, disease burden (using the Deyo score), and clustering of patients within VA medical centers. IV. Results. Among 14,252 veterans 99% were male, 70% were between 55 and 75 years old, and 30% were > 75 years. 63% died within 6 months of being identified for the study. 60.5% of patients were Caucasian; 34.5%, African American; and 5%, Hispanic. Both differences and commonalities were found by race/ethnicity. African Americans were less likely to be intubated (OR = .82 [.70-.86]; P = .0001), resuscitated (OR = .724 [.63-.83]; P = .0001), and had a trend toward receiving less ICU care (OR = .93 [.88-.99]; P = .019) than Caucasians; however, they were slightly more likely to receive transfusions. Hispanics were more likely to be transfused (OR = 1.214 [1.071-1.376]; P = .003), resuscitated (OR = 1.31 [1.02-1.68]; P = .035), or in the ICU (OR = 1.18 [1.04-1.34]; P = .013) than Caucasians. No differences were found for enteral feeding by race/ethnicity. Younger patients were more likely to receive intubation, resuscitation, or ICU care than older patients, but there was no difference for transfusion or enteral feeding by age group. V. Conclusions. Differences in level of end-oflife treatments were bidirectional for African Americans. VI. Implications for research, policy, or practice. In the absence of generally accepted, evidencebased standards for end-of-life care, these differences may or may not constitute disparities. However, it is of concern that African Americans received less intubation, resuscitation, and ICU care than Caucasians in light of many studies on patient preferences showing African Americans generally preferring more aggressive end-of-life care.