Treatment Intensity at the End of Life in Older Adults Receiving Long-term Dialysis FREE

Life expectancy after the initiation of long-term dialysis is often severely limited in the elderly,¹ and it is becoming increasingly clear that many older patients who are receiving dialysis experience a significant burden of concomitant illness,² functional limitation,³ and symptoms.⁴ Such considerations have fostered a growing interest in end-of-life care and advanced care planning in this population.

Relatively little is known about the contemporary patterns and determinants of end-of-life care among older patients who are receiving long-term dialysis. Available data indicate that hospice referral is infrequent in this population and that rates of hospice referral and dialysis discontinuation vary substantially across regions.⁵ To our knowledge, detailed information on other aspects of health care utilization at the end of life, including hospitalization, intensive care unit (ICU) admission, and use of intensive procedures, has not been reported for this population. Herein, we present the results of a retrospective mortality study to characterize the end-of-life care practices among older Medicare beneficiaries who are receiving long-term dialysis.

Using data from the United States Renal Data System (USRDS), a comprehensive registry for end-stage renal disease (ESRD), we identified 99 329 fee-for-service Medicare patients aged 65 years and older who initiated long-term dialysis between January 1, 2004, and December 31, 2007, and died before January 1, 2009. Information regarding their sociodemographic background, coexisting illnesses at onset of dialysis, primary cause of ESRD, primary cause of death, and whether they were referred to hospice before death was extracted from USRDS files. This study was approved by the institutional review board at the University of Washington, Seattle.

Using inpatient and outpatient Medicare claims supplied by the USRDS, we ascertained information on hospitalization, ICU admission, and use of the following intensive procedures during the final month of life: mechanical ventilation, feeding tube placement, and cardiopulmonary resuscitation. Patients were assigned to a hospital referral region based on their zip code at the onset of ESRD. We used an end-of-life care expenditure index (EOL-EI) based on deaths between 2000 and 2003 from the Dartmouth Atlas of Health Care (http://www.dartmouthatlas.org/) to characterize each region's level of health care spending among older Medicare beneficiaries during the last 6 months of life.⁶ Regions were categorized into quintiles of EOL-EI, with the first quintile representing regions with the lowest EOL-EI; and the fifth quintile, regions with the highest. Using multivariate logistic regression, we measured the association of individual patient characteristics and quintile of EOL-EI with hospitalization, ICU admission, and use of intensive procedures during the final month of life.

Altogether, 76.0% of patients were hospitalized, 48.9% were admitted to an ICU, and 29.0% received at least 1 intensive procedure during the final month of life. The most common procedure was mechanical ventilation (22.2%), followed by cardiopulmonary resuscitation (11.9%) and feeding tube placement (3.9%).

In adjusted analyses, use of intensive procedures was more common among patients who were black (40.9% vs 35.6%; odds ratio [OR], 1.68; 95% CI, 1.61-1.76), who were 75 years or younger (34.7% vs 24.8%; OR, 1.48; 95% CI, 1.43-1.54), and who died of cardiovascular causes (35.4% vs 25.2%; OR, 1.39; 95% CI, 1.34-1.44). Use of intensive procedures did not differ greatly by sex, cause of ESRD, comorbid illness, or duration on long-term dialysis (data available on request). After differences in patient characteristics were adjusted for, patients living in regions in the highest quintile of EOL-EI as compared with the lowest quintile of EOL-EI were more likely to be hospitalized (79.7% vs 69.0%; OR, 1.60; 95% CI, 1.50-1.71), to be admitted to an ICU (55.5% vs 40.9%; OR, 1.62; 95% CI, 1.54-1.71), and to undergo an intensive procedure (36.4% vs 20.1%; OR, 1.61; 95% CI, 1.51-1.71) during the final month of life.

Older Medicare beneficiaries who are receiving long-term dialysis experience very high rates of hospitalization, ICU admission, and use of intensive procedures during the final month of life. Intensity of care at the end of life in this population is substantially higher than that reported for other Medicare beneficiaries with life-limiting illnesses (Table).^7- 9 Receipt of intensive procedures was more strongly and consistently associated with level of regional health care spending than with individual patient characteristics. While patterns of end-of-life care should ideally reflect patient values and preferences, these findings appear to suggest that end-of-life care among older patients who are receiving dialysis may be driven more by practice-related factors.