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Clin J Am Soc Nephrol. 2019 Aug 7;14(8):1200-1212. doi: 10.2215/CJN.00290119. Epub 2019 Jul 18.

Expanded Prospective Payment System and Use of and Outcomes with Home Dialysis by Race and Ethnicity in the United States.

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Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California;
Department of Medicine, David Geffen School of University of California at Los Angeles, Los Angeles, California.
Section of Nephrology and Selzman Institute for Kidney Health and Center, Baylor College of Medicine, Houston, Texas.
Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California.
Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California; and.
Health Services Research Unit, The Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada.



We investigated whether the recent growth in home dialysis use was proportional among all racial/ethnic groups and also whether there were changes in racial/ethnic differences in home dialysis outcomes.


This observational cohort study of US Renal Data System patients initiating dialysis from 2005 to 2013 used logistic regression to estimate racial/ethnic differences in home dialysis initiation over time, and used competing risk models to assess temporal changes in racial/ethnic differences in home dialysis outcomes, specifically: (1) transfer to in-center hemodialysis (HD), (2) mortality, and (3) transplantation.


Of the 523,526 patients initiating dialysis from 2005 to 2013, 55% were white, 28% black, 13% Hispanic, and 4% Asian. In the earliest era (2005-2007), 8.0% of white patients initiated dialysis with home modalities, as did a similar proportion of Asians (9.2%; adjusted odds ratio [aOR], 0.95; 95% confidence interval [95% CI], 0.86 to 1.05), whereas lower proportions of black [5.2%; aOR, 0.71; 95% CI, 0.66 to 0.76] and Hispanic (5.7%; aOR, 0.83; 95% CI, 0.86 to 0.93) patients did so. Over time, home dialysis use increased in all groups and racial/ethnic differences decreased (2011-2013: 10.6% of whites, 8.3% of blacks [aOR, 0.81; 95% CI, 0.77 to 0.85], 9.6% of Hispanics [aOR, 0.94; 95% CI, 0.86 to 1.00], 14.2% of Asians [aOR, 1.04; 95% CI, 0.86 to 1.12]). Compared with white patients, the risk of transferring to in-center HD was higher in blacks, similar in Hispanics, and lower in Asians; these differences remained stable over time. The mortality rate was lower for minority patients than for white patients; this difference increased over time. Transplantation rates were lower for blacks and similar for Hispanics and Asians; over time, the difference in transplantation rates between blacks and Hispanics versus whites increased.


From 2005 to 2013, as home dialysis use increased, racial/ethnic differences in initiating home dialysis narrowed, without worsening rates of death or transfer to in-center HD in minority patients, as compared with white patients.


Asian Continental Ancestry Group; Cohort Studies; Ethnic Groups; European Continental Ancestry Group; Hemodialysis, Home; Hispanic Americans; Logistic Models; Odds Ratio; Prospective Payment System; disparities; ethnicity; home dialysis; modality selection; outcomes; peritoneal dialysis; race; renal dialysis; technique failure; temporal trends

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