Study examines differences over time in home dialysis initiation by race and ethnicity

Highlights

• Among U.S. patients who started dialysis in 2005 to 2013, racial/ethnic differences in initiating home dialysis decreased over time, although in the most recent era, Blacks were still less likely to use home dialysis as the initial modality than other groups.
• Racial/ethnic differences in transfer from home dialysis to hemodialysis performed in dialysis facilities did not change over time.
• Minority patients continued to have lower mortality and kidney transplantation rates than White patients.

Washington, DC (July 18, 2019) -- A recent analysis reveals that as home dialysis increased from 2005 to 2013 among U.S. patients with kidney failure, racial/ethnic differences in initiating home dialysis narrowed. The findings, which appear in an upcoming issue of CJASN, indicate that all racial/ethnic groups are increasingly using this form of dialysis.

Dialysis is a life-saving treatment for many individuals with kidney failure that can be done either at home by the patient or at a dialysis facility by trained personnel. The use of home dialysis in the United States has increased over the last 10 years due to payment reforms and educational efforts. Because home dialysis provides patients with more autonomy and flexibility, it is important that all patients are educated about and offered home dialysis as an option.

Historically, minority patients have been less likely to use home dialysis than non-Hispanic White patients. To examine whether the recent growth in home dialysis use was proportional among all racial/ethnic groups, Jenny Shen, MD, MS (Los Angeles Biomedical Institute at Harbor-UCLA Medical Center) and her colleagues analyzed information on all patients listed in the United States Renal Data System who initiated dialysis from 2005 to 2013.

Of the 523,526 patients initiating dialysis from 2005 to 2013, 55% were White, 28% Black, 13% Hispanic, and 4% Asian. Among the study's findings:

• In the earliest era (2005 to 2007), 8.0% of White patients initiated dialysis with home modalities, as did a similar proportion of Asians (9.2%), while lower proportions of Black (5.2%) and Hispanic (5.7%) patients did so.
• Over time, home dialysis use increased in all groups and racial/ethnic differences decreased. In 2011 to 2013, rates were 10.6% for Whites, 8.3% for Blacks, 9.6% for Hispanics, and 14.2% for Asians.
• Compared with White patients, the risk of transferring to in-center hemodialysis was higher in Blacks, similar in Hispanics, and lower in Asians, and these differences remained stable over time.
• The mortality rate was lower for minority patients than for White patients, and this difference increased over time.
• Transplantation rates were lower for Blacks and similar for Hispanics and Asians, and the difference in transplantation rates between Blacks and Hispanics vs. Whites increased over time.

"The nephrology community has been understandably pleased by the increase in the use of home dialysis in the past decade. It was important to study whether all racial and ethnic groups have experienced this rise in home dialysis use or whether some groups had continued to lag behind," said Dr. Shen. "We found that racial and ethnic differences in the initiation of dialysis with home dialysis have narrowed without any deleterious impact in relative rates of transfer to in-center hemodialysis and death."

In an accompanying editorial, Kerri Cavanaugh, MD, MHS (Vanderbilt University Medical Center) noted that "although disparities remain in the use of home dialysis by race/ethnicity in the U.S., there is optimism that this will be a statistic of the past as we keep it front and center as we show that health equity is an achievable outcome when the many talents, resources, and compassion of the nephrology community come together."

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Study co-authors include Kevin Erickson, MD, MS, Lucia Chen, MS, Sitaram Vangala, MS, Lynn Leng, BS, Anuja Shah, MD, Anjali B. Saxena, MD, Jeffrey Perl MD, SM, and Keith C. Norris, MD, PhD.

Disclosures: Dr. Erickson reports personal fees from Acumen LLC., outside the submitted work. Dr. Perl reports grants from Canadian Institute for Health Research, grants from Baxter Healthcare, personal fees from Arbor Research Collaborative for Health, during the conduct of the study; personal fees from Baxter Healthcare, personal fees from Fresenius Medical Care, personal fees from DaVita Healthcare, personal fees from DCI, and personal fees from Satellite Healthcare, outside the submitted work. Dr. Saxena reports personal fees from Baxter Healthcare and personal fees from Fresenius, outside the submitted work. Dr. Shen reports personal fees from Baxter, outside the submitted work. Dr. Chen, Ms. Leng, Dr. Norris, and Dr. Vangala have nothing to disclose.

The article, entitled "Expanded Prospective Payment System and Use of and Outcomes with Home Dialysis by Race and Ethnicity in the United States," will appear online at http://cjasn.asnjournals.org/ on July 18, 2019, doi: 10.2215/CJN.11590918.

The editorial, entitled "Public Policy and Equal Access to Home Dialysis," will appear online at http://cjasn.asnjournals.org/ on July 18, 2019.

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