Health Services Research & Development

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2006 HSR&D National Meeting Abstract


3005 — Geography Matters: Residential Segregation by Race and Dialysis Patient and Facility Outcomes

Author List:
O'Hare AM (REAP San Francisco, UCSF)
Mehta K (REAP San Francisco, UCSF)
Moody-Ayers S (REAP San Francisco, UCSF)
Sen S (REAP San Francisco, UCSF)
Rodriguez RA (UCSF, San Francisco General Hospital)

Objectives:
End-stage renal disease disproportionately affects black Americans. However, the impact of residential segregation by race, a prominent feature of many American cities, on dialysis patient and facility outcomes has not been evaluated. Our objective was to measure the association between the residential composition of the urban area in which dialysis patients live and in which dialysis facilites are located with patient and facility outcomes.

Methods:
We conducted separate analyses to examine the characteristics and outcomes of black and non-Hispanic white patients who initiated chronic dialysis between January 1, 1995 and December 31, 2002 (n=383,417) living in metropolitan zip codes with differing percentages of black residents (<10, 10-24, 25-49, 50-74 and =75 percent). We also examined characteristics and outcomes of prevalent dialysis facilities (n=3,244) located in these areas. Analyses were based on data from the United States Renal Data System, the Center for Medicare and Medicaid’s (CMS) Dialysis Facility Compare database and the 2000 United States Census.

Results:
Black and white dialysis patients tended to live in different residential areas. For example, metropolitan zip codes with =50% black residents (n=770) were home to 50% of all black but only 4% of all white cohort patients. Regardless of race, mortality rates were higher and kidney transplant rates lower among patients living in areas with a higher percentage of black residents. Dialysis facilities located in areas with a higher percentage of black residents were more likely to have higher than expected mortality rates, less likely to offer home-based therapies (peritoneal and home hemodialysis) or an evening shift of dialysis, and less likely to meet performance targets.

Implications:
Dialysis patients and dialysis facilities located in areas with a high percentage of black residents have worse outcomes than in other areas.

Impacts:
Programs to improve access to kidney transplantation targeted at black residential areas may help to reduce black-white disparities in transplantation rates. In addition, policies that link reimbursement for dialysis to facility or patient outcomes may adversely impact dialysis facilities and patients located in these resource-poor areas.