Elucidating the Mechanisms of Racial and Ethnic Disparities in Dialysis Quality

(PLEASE KEEP IN WORD, DO NOT PDF) Dialysis, the mainstay of treatment for end-stage kidney disease (ESKD), afflicts more than 800,000 in the US and has a 60% five-year mortality rate, more than that of many cancers and other chronic illnesses. ESKD is one of the starkest examples of racial and ethnic disparities in healthcare. Over 50% of individuals on dialysis are Black or Latino. And once on dialysis, Black and Latino patients are more likely to receive low quality care. While researchers have described these disparities in ESKD, there are notable gaps in the literature. First, most of the literature has not examined specific mechanisms contributing to these disparities or quantified their effects. For instance, although researchers have identified neighborhood-, provider-, and individual-level contributors to disparities, research examining their joint effect is limited. Second, researchers have not extensively examined these mechanisms at a regional level. Third, researchers have not attempted to project the impact of future policies or interventions aimed at ameliorating disparities in dialysis. The proposed project will address these knowledge gaps. Using a national registry of all patients receiving dialysis in the US linked to Medicare claims, we will examine mechanisms that contribute to disparities in dialysis care. Aim 1 will assess the extent to which disparities occur at the neighborhood- and individual-level. A key innovation from this Aim is the evaluation of these mechanisms both within and between regional areas. Aim 2 will study an example of financial incentives that could potentially alleviate disparities: bonus payments to safety-net providers. We will use quasi-experimental methods to assess the effect of facilities losing or gaining these bonus payments. This work is significant because it will inform researchers, healthcare providers, and policymakers about mechanisms that drive disparities in dialysis, which has disproportionately poor outcomes and which uniquely burdens racial and ethnic minorities. Additionally, we will examine whether financial incentives could alleviate these burdens. When completed, these Aims will guide researchers, healthcare providers, and policymakers to design future interventions and research studies with the goal of eliminating racial and ethnic disparities in dialysis.