Trends and Racial Disparities of Palliative Care Use among Hospitalized Patients with ESKD on Dialysis

Significance Statement Studies have shown significant racial and ethnic disparities in the end-of-life care received by dialysis patients with ESKD in the United States, but little is known about disparity in the palliative care services received by such patients in the inpatient setting. This retrospective cohort study of 5,230,865 hospitalizations of patients on dialysis found that, despite a significant increase in use of palliative care services from 2006 through 2014, such services remained underused. Black and Hispanic patients were less likely than white patients to receive palliative care services in the hospital, disparities that persisted in all hospital subtypes, including hospitals with a high proportion of minority patients. These results complement previous findings and highlight the importance of further investigation of systemic issues contributing to barriers and racial disparities in palliative care use. Background Study findings show that although palliative care decreases symptom burden, it is still underused in patients with ESKD. Little is known about disparity in use of palliative care services in such patients in the inpatient setting. Methods To investigate the use of palliative care consultation in patients with ESKD in the inpatient setting, we conducted a retrospective cohort study using the National Inpatient Sample from 2006 to 2014 to identify admitted patients with ESKD requiring maintenance dialysis. We compared palliative care use among minority groups (black, Hispanic, and Asian) and white patients, adjusting for patient and hospital variables. Results We identified 5,230,865 hospitalizations of such patients from 2006 through 2014, of which 76,659 (1.5%) involved palliative care. The palliative care referral rate increased significantly, from 0.24% in 2006 to 2.70% in 2014 ( P <0.01). Black and Hispanic patients were significantly less likely than white patients to receive palliative care services (adjusted odds ratio [aOR], 0.72; 95% confidence interval [95% CI], 0.61 to 0.84, P <0.01 for blacks and aOR, 0.46; 95% CI, 0.30 to 0.68, P <0.01 for Hispanics). These disparities spanned across all hospital subtypes, including those with higher proportions of minorities. Minority patients with lower socioeconomic status (lower level of income and nonprivate health insurance) were also less likely to receive palliative care. Conclusions Despite a clear increase during the study period in provision of palliative care for inpatients with ESKD, significant racial disparities occurred and persisted across all hospital subtypes. Further investigation into causes of racial and ethnic disparities is necessary to improve access to palliative care services for the vulnerable ESKD population.