JAMA logoIf the kidneys are unable to function accurately, an individual may develop end-stage renal disease (ESRD). Apparently many treatment choices are available for the disease. Investigators claim that an ample amount of regional differences appear in treatment practices for care of older adults with ESRD, namely receipt of hospice care and discontinuation of dialysis before death.

Amongst all the patents with ESRD, patients aged 75 years or older at present seem to symbolize one of the fastest growing groups. The experts estimate that the Average Medicare costs for an older patient receiving long-term dialysis to be more than $100,000 during the first year after initiation of therapy itself. Treatment practices adopted for older adults with this ailment are supposedly not well known and the extent to which these practices vary regionally.

The scientists explained, “Among decedents, dialysis was discontinued prior to death in 44.3 percent of those living in regions in the lowest end-of-life expenditure index quintile compared with 22.2 percent of those living in regions in the highest quintile. From the lowest to the highest end-of-life expenditure index quintile, the proportion of patients who received hospice care before death ranged from 33.5 percent to 20.7 percent, and the proportion who died in the hospital ranged from 50.3 percent to 67.8 percent.”

At the time of the study, the scientists inspected the occurrence of ESRD and end-of-life care practices among older adults with ESRD across regions with differing intensities of care. Data accumulated from a national ESRD registry was utilized to analyze a group of 41,420 adults belonging to the white or black race. All the patients were aged 65 years or older and between June 1, 2005 and May 31, 2006 and these patients had started long-term dialysis or received a kidney transplant. Having employed an index from the Dartmouth Atlas of Healthcare, the authors ascertained the regional end-of-life intensity of care.

After the completion of all the investigations, Ann M. O’Hare, M.D., M.A., of the University of Washington and VA Puget Sound Healthcare System, Seattle, and colleagues revealed that in regions with greater intensity of care, whites have a gradually higher incidence of ESRD. The experts mentioned that the results were noted among the older adults.

The experts added, “There is substantial, unexplained regional variation in the care of older adults with ESRD, both prior to ESRD onset and prior to death. This finding underlines the importance of a comprehensive informed and ongoing consent process for ESRD treatment based on available evidence and clinical practice guidelines. Such efforts will help to ensure that treatment decisions— including those to initiate and to discontinue dialysis—are based on patient preferences and values rather than regional practice style. Ultimately, improved decision making for dialysis initiation and discontinuation may serve as a valuable model for the use of other high-cost, intensive treatments in older adults.”

Even among blacks an identical relationship was determined but only in men aged 80 years or older and women aged 85 years of age or older. The study authors compared the patients in regions in the highest with those in the lowest quintile of end-of-life intensity of care. It appeared that patients in the highest in regions with greater intensity of care were less likely to be under the care of a nephrologist, who is a physician diagnosing people with kidney disease before the access of ESRD.

If the statistics are to be believed then, 62.3 percent people are likely to receive the required treatment in comparison to 71.1 percent people from the lowest quintile. 11.2 percent patients in the highest group were less likely to have a fistula that is known to be created by a surgical procedure after connecting an artery to a vein, usually in the forearm, further providing access for dialysis. On the other hand, 16.9 percent receive graft or catheter at the time of hemodialysis initiation.

The scientists mentioned that overall 51 percent patients wherein 21,190 died in 2 years of the occurrence of ESRD. Patients in regions in the lowest end-of-life expenditure index quintile displayed 47.1 percent and patients in regions in the highest quintile revealed 52.6 percent. It is mentioned that the regional differences in practice were not explained by differences in patient characteristics measured at the onset of ESRD.

The study is published in the July 14 issue of JAMA.