Healthcare Intensity at Initiation of Chronic Dialysis among Older Adults

Little is known about the circumstances under which older adults initiate chronic dialysis and subsequent outcomes. Using national registry data, we conducted a retrospective analysis of 416,657 Medicare beneficiaries aged ≥67 years who initiated chronic dialysis between January 1995 and December 2008. Our goal was to define the relationship between health care intensity around the time of dialysis initiation and subsequent survival and patterns of hospitalization, use of intensive procedures (mechanical ventilation, feeding tube placement, and cardiopulmonary resuscitation), and discontinuation of dialysis before death. We found that most patients (64.5%) initiated dialysis in the hospital, including 36.6% who were hospitalized for ≥2 weeks and 7.4% who underwent one or more intensive procedures. Compared with patients who initiated dialysis in the outpatient setting, those who received the highest intensity of care at dialysis initiation (those hospitalized ≥2 weeks and receiving at least one intensive procedure) had a shorter median survival (0.7 versus 2.1 years; P<0.001), spent a greater percentage of remaining follow-up time in the hospital (median, 22.9% versus 3.1%; P<0.001), were more likely to undergo subsequent intensive procedures (44.9% versus 26.0%; adjusted hazard ratio, 2.33; 95% confidence interval [CI], 2.27 to 2.39), and were less likely to have discontinued dialysis before death (19.1% versus 26.2%; adjusted odds ratio, 0.68; 95% CI, 0.65 to 0.72). In conclusion, most older adults initiate chronic dialysis in the hospital. Those who have a prolonged hospital stay and receive other forms of life support around the time of dialysis initiation have limited survival and more intensive patterns of subsequent healthcare utilization.Over the last decade, a growing number of older adults are initiating chronic dialysis.¹ Survival among these older patients is extremely limited,^2,3 and many experience functional decline,^4,5 frequent hospitalization,⁶ and a high symptom burden⁷ after initiation of chronic dialysis. In this setting, patients must often make trade-offs between interventions intended to lengthen life and those directed at other treatment goals, such as maximizing quality of life and maintaining independence.Rates of hospitalization and use of intensive procedures, such as mechanical ventilation, feeding tube placement, and cardiopulmonary resuscitation (CPR), at the end of life are exceptionally high in older dialysis patients compared with other older Medicare beneficiaries with life-limiting illness.⁸ Discussions about prognosis, goals, and preferences are often lacking, and patients may have little appreciation of their likelihood of clinical deterioration or knowledge of more conservative alternatives, such as hospice.⁹ Uncertainty about disease trajectory and prognosis can hamper formulation of future plans and treatment preferences.^10–12Prior studies have evaluated the association of patient characteristics (e.g., comorbid conditions and functional status)^5,13,14 and treatment practices (e.g., early nephrology referral and type of vascular access)^15,16 before and at the time of dialysis initiation with subsequent outcomes. However, many of these analyses did not capture information on clinical circumstances around the time of dialysis initiation. In reality, chronic dialysis is often initiated in the context of acute illness^17,18 and rapid or unexpected loss of renal function.¹⁴We hypothesized that illness severity around the time of dialysis initiation—as reflected in measures of health care intensity, such as length of hospitalization and use of intensive procedures—might provide information useful for anticipatory guidance and supporting treatment decisions in older adults newly initiated on chronic dialysis. To evaluate this hypothesis, we used data from the U.S. Renal Data System (USRDS), a national registry of ESRD, to identify 416,657 Medicare beneficiaries aged ≥67 years and describe the intensity of care they experienced around the time of initiation of chronic dialysis and its association with survival and patterns of future healthcare utilization.