Socioeconomic Factors and Racial and Ethnic Differences in the Initiation of Home Dialysis

RATIONALE & OBJECTIVE: Home dialysis has been underused in the United States, especially among minority groups. We investigated whether adjustment for socioeconomic factors would attenuate racial/ethnic differences in the initiation of home dialysis. STUDY DESIGN: Retrospective observational cohort study. SETTING & POPULATION: Adult patients in the US Renal Data System who initiated dialysis on day 1 with either in-center hemodialysis (HD), home HD (HHD), or peritoneal dialysis (PD) from 2005 to 2013. PREDICTOR: Race/ethnicity: non-Hispanic white, Hispanic, black, or Asian. OUTCOME: Initiating dialysis with PD versus in-center HD and HHD versus in-center HD for each minority group compared with non-Hispanic whites. ANALYTICAL APPROACH: Odds ratios and 95% CIs estimated by logistic regression. RESULTS: Of 523,526 patients, 55% were white, 28% were black, 13% were Hispanic, and 4% were Asian; 8% started dialysis on PD, and 0.1%, on HHD. In unadjusted analyses, blacks and Hispanics were 30% and 19% less likely and Asians were 31% more likely to start on PD than whites. The differences narrowed when fully adjusted for demographic, medical, and socioeconomic factors. Adjustment for socioeconomic factors reduced these differences between white and black, Hispanic, and Asian patients by 13%, 28%, and 1%, respectively. Blacks were just as likely and Hispanics and Asians were less likely to start on HHD than whites. This did not change appreciably when fully adjusted for demographic, medical, and socioeconomic factors. LIMITATIONS: No data for physician and patient preferences or modality education. CONCLUSIONS: Black and Hispanic patients are less likely to start on PD than white patients, attributable partly, though not completely, to socioeconomic factors. Hispanics and Asians are less likely to start on HHD than whites. This was materially unaffected by socioeconomic factors. More research is needed to determine whether urgent-start PD programs and transitional care units in socioeconomically disadvantaged areas might reduce these disparities and increase home dialysis use among all groups.