Abstract: FR-PO910

Geographic Income Inequality and End-of-Life Care in US Dialysis Patients, 2000 to 2011

Session Information

Category: Dialysis

  • 609 Dialysis: Palliative and End-of-Life Care


  • Foley, Robert N., University of Minnesota, Minneapolis, Minnesota, United States
  • Reule, Scott, University of Minnesota, Minneapolis, Minnesota, United States

End-of-life care is increasingly considered in dialysis patients when death is imminent and quality of life is poor. Although end-of-life care can add financial and other burdens to dialysis patients and their families, associations with regional income dispersion have not been examined. As little is known regarding geographic income inequality, we performed a national study to examine potential associations with end-of-life care in US dialysis patients.


Retrospective United States Renal Data System files were used to end-of-life care parameters (all deaths from 2000 to 2011, N=910,559). The main exposure variable was county-level Gini index of income dispersion (range: 0 [perfect equality] to 1 [perfect inequality]; observed quartile thresholds 0.430, 0.453 and 0.481).


The primary outcome-a composite of withdrawal of dialysis and death in a non-hospital or hospice setting-decreased monotonically with increasing income dispersion (20.9%, 18.6%, 17.0% and 10.2%, respectively, for Quartiles 1 to 4 of Gini index, P-Value < 0.001). Similarly, monotonic patterns (P-Value < 0.001 throughout) were seen for dialysis withdrawal (30.0%, 27.3%, 25.2% and 16.0%), hospice (15.1%, 14.1%, 13.3% and 9.0%) and non-hospital death (44.5%, 41.9%, 40.1% and 33.3%). After adjustment for age, sex, race-ethnicity, region, urban or rural domicile, kidney disease, mode of dialysis, previous transplant, insurance and dialysis facility characteristics, the primary outcome was similarly less likely in Quartiles 2 (adjusted odds ratio [AOR] 0.91 [95% CI 0.89-0.92], [Vs. Quartile 1]) and 3 (AOR 0.90 [0.88-0.91]) and even less likely in Quartile 4 (AOR 0.61 [0.61-0.62]), a pattern that was repeated when dialysis withdrawal, hospice and non-hospital death were examined (P-Value < 0.001 for each AOR). Multivariate associations between income dispersion and end-of-life care were present in all 45 subgroups examined.


End-of-life care in dialysis patients varies meaningfully by geographic income inequality.