Regional Variation in Health Care Intensity and Treatment Practices for End-stage Renal Disease in Older Adults
Regional Variation in Health Care Intensity and Treatment Practices for End-stage Renal Disease in Older Adults
复制标题
DOI：
10.1001/jama.2010.924
复制
发表时间：
2010-07-14
影响因子：
120.7
通讯作者：
Tamura, Manjula Kurella
中科院分区：
文献类型：
--
作者：
O'Hare, Ann M.;Rodriguez, Rudolph A.;Tamura, Manjula Kurella
背景越来越多的老年人接受终末期肾病（ESRD）的长期透析治疗。目的：确定不同地区老年人ESRD治疗实践的差异以及不同的临终护理强度。设计、设置和参与者：回顾性观察性研究，使用国家ESRD登记处确定41420名成年人队列（白色或黑人），年龄65岁或以上，在2005年6月1日至2006年5月31日期间开始长期透析或接受肾移植。使用达特茅斯医疗保健地图集中的一个指数来定义区域性终末期护理强度。主要结果测量接受治疗的ESRD的发生率（透析或移植），ESRD准备（在肾脏科医生的护理下，在血液透析开始时有瘘管[vs移植物或导管]），和生命终了护理实践。终末期肾病的发病率在护理强度较大的地区逐渐升高，这一趋势在老年人中最为明显。在黑人中，类似的关系仅在高龄（男性年龄>= 80岁，女性年龄>= 85岁）时存在。生活在临终关怀强度最高和最低五分位数地区的患者在ESRD发作前接受肾病学家护理的可能性较低（62.3% [95%置信区间{CI}，61.3%-63.3%] vs 71.1% [95% CI，69.9%-72.2%]，在血液透析开始时发生瘘的可能性较小（与移植物或导管相比）（11.2% [95% CI，10.6%-11.8%] vs 16.9% [95% CI，15.9%-17.8%]）。在ESRD发作后2年内死亡的患者中（n= 21190），与最低五分位数相比，生活在临终关怀强度最高的地区的人在死亡前停止透析的可能性较小（分别为22.2% [95% CI，21.1%-23.4%] vs 44.3% [95% CI，42.5%-46.1%]），不太可能接受临终关怀（20.7% [95% CI，19.5%-21.9%] vs 33.5% [95% CI，31.7%-35.4%]），更可能在医院死亡（67.8% [95% CI，66.5%-69.1%] vs 50.3% [95% CI，48.5%-52.1%]）。这些差异持续调整analysis.Conclusion有显着的区域差异，在治疗实践中，老年人终末期肾病的患者特征的差异不能解释。JAMA. 2010; 304（2）：180-186 www.jama.com
Context An increasing number of older adults are being treated for end-stage renal disease (ESRD) with long-term dialysis.Objectives To determine how ESRD treatment practices for older adults vary across regions with differing end-of-life intensity of care.Design, Setting, and Participants Retrospective observational study using a national ESRD registry to identify a cohort of 41 420 adults (of white or black race), aged 65 years or older, who started long-term dialysis or received a kidney transplant between June 1, 2005, and May 31, 2006. Regional end-of-life intensity of care was defined using an index from the Dartmouth Atlas of Healthcare.Main Outcome Measures Incidence of treated ESRD (dialysis or transplant), preparedness for ESRD (under the care of a nephrologist, having a fistula [vs graft or catheter] at time of hemodialysis initiation), and end-of-life care practices.Results Among whites, the incidence of ESRD was progressively higher in regions with greater intensity of care and this trend was most pronounced at older ages. Among blacks, a similar relationship was present only at advanced ages (men aged >= 80 years and women aged >= 85 years). Patients living in regions in the highest compared with lowest quintile of end-of-life intensity of care were less likely to be under the care of a nephrologist before the onset of ESRD (62.3% [95% confidence interval {CI}, 61.3%-63.3%] vs 71.1% [95% CI, 69.9%-72.2%], respectively) and less likely to have a fistula (vs graft or catheter) at the time of hemodialysis initiation (11.2% [95% CI, 10.6%-11.8%] vs 16.9% [95% CI, 15.9%-17.8%]). Among patients who died within 2 years of ESRD onset (n=21 190), those living in regions in the highest compared with lowest quintile of end-of-life intensity of care were less likely to have discontinued dialysis before death (22.2% [95% CI, 21.1%-23.4%] vs 44.3% [95% CI, 42.5%-46.1%], respectively), less likely to have received hospice care (20.7% [95% CI, 19.5%-21.9%] vs 33.5% [95% CI, 31.7%-35.4%]), and more likely to have died in the hospital (67.8% [95% CI, 66.5%-69.1%] vs 50.3% [95% CI, 48.5%-52.1%]). These differences persisted in adjusted analyses.Conclusion There are pronounced regional differences in treatment practices for ESRD in older adults that are not explained by differences in patient characteristics. JAMA. 2010; 304(2): 180-186 www.jama.com