Home Dialysis Utilization Among Racial and Ethnic Minorities in the United States at the National, Regional, and State Level.

♦ BACKGROUND: United States Renal Data System (USRDS) data from 2014 show that African Americans (AA) are underrepresented in the home dialysis population, with 6.4% versus 9.2% utilization in the general populace. This racial disparity may be inaccurately ascribed to the nation as a whole if regional and inter-state variability exists. This investigation sought to examine home dialysis utilization by minority Medicare beneficiary populations across the US nationally, regionally, and by individual state. ♦ METHODS: The 2012 Medicare 100% Outpatient Standard Analytic File was used to identify all Medicare fee-for-service (FFS) patients, with state of residence and race, receiving an outpatient dialysis facility bill type. Peritoneal dialysis (PD) and home hemodialysis (HHD) patients were identified using revenue and condition codes and were defined by having at least one claim during the year that met criteria for the category. Beneficiaries were counted once for each modality used that year. A home dialysis utilization ratio (UR) was calculated as the ratio of the proportion of a minority on PD or HHD within a geographic division to the proportion of Caucasians on PD or HHD within the same geographic division. A UR less than 1.00 indicated under-representation while a UR over 1.00 indicated over-representation. Utilization ratios were compared using a Poisson regression model. ♦ RESULTS: A total of 369,164 Medicare FFS dialysis patients were identified. Within the total cohort, AA were the most underrepresented minority on PD (UR 0.586; 95% confidence interval [CI]: 0.585 - 0.586; p < 0.0001), followed by Hispanics (UR 0.744; 95% CI 0.743 - 0.744; p < 0.0001). The underutilization of PD by AA and Hispanics could not be ascribed to any region of the US, as all regions of the US had UR < 1.00. Only Massachusetts had a UR > 1.00 for AA on PD. Peritoneal dialysis UR values for Asians and those self-identified as Other were 0.954; 95% CI 0.953 - 0.954 and 0.932; 95% CI 0.931 - 0.932, respectively. Nationally, all minorities utilized HHD less than Caucasians. However, more variability existed, with Asians utilizing more HHD than Caucasians in the Midwest. ♦ CONCLUSIONS: Although regional and interstate variability exists, there is near universal under-representation of AA and Hispanics in the home dialysis population, while Asians and Other demonstrate more interregional and interstate variability.

Infectious diseases specialty intervention is associated with decreased mortality and lower healthcare costs.

BACKGROUND: Previous studies, largely based on chart reviews with small sample sizes, have demonstrated that infectious diseases (ID) specialists positively impact patient outcomes. We investigated how ID specialists impact mortality, utilization, and costs using a large claims dataset. METHODS: We used administrative fee-for-service Medicare claims to identify beneficiaries hospitalized from 2008 to 2009 with at least 1 of 11 infections. There were 101 991 stays with and 170 336 stays without ID interventions. Cohorts were propensity score matched for patient demographics, comorbidities, and hospital characteristics. Regression models compared ID versus non-ID intervention and early versus late ID intervention. Risk-adjusted outcomes included hospital and intensive care unit (ICU) length of stay (LOS), mortality, readmissions, hospital charges, and Medicare payments. RESULTS: The ID intervention cohort demonstrated significantly lower mortality (odds ratio [OR], 0.87; 95% confidence interval [CI], .83 to .91) and readmissions (OR, 0.96; 95% CI, .93 to .99) than the non-ID intervention cohort. Medicare charges and payments were not significantly different; the ID intervention cohort ICU LOS was 3.7% shorter (95% CI, -5.5% to -1.9%). Patients receiving ID intervention within 2 days of admission had significantly lower 30-day mortality and readmission, hospital and ICU length of stay, and Medicare charges and payments compared with patients receiving later ID interventions. CONCLUSIONS: ID interventions are associated with improved patient outcomes. Early ID interventions are also associated with reduced costs for Medicare beneficiaries with select infections.