Open AccessCounty-Level Characteristics Associated with Variation in ESKD Mortality in the United States, 2010–2018
Author(s) -
Kylie Snow,
Rachel E. Patzer,
Shivani A. Patel,
Jessica L. Harding
Publication year - 2022
Publication title -
kidney360
Language(s) - English
Resource type - Journals
ISSN - 2641-7650
DOI - 10.34067/kid.0007872021
Subject(s) - demography , socioeconomic status , poverty , medicine , mortality rate , regional variation , geography , gerontology , environmental health , population , sociology , political science , law , economics , economic growth
Background: Geographic and neighborhood-level factors such as poverty and education have been associated with an increased risk for incident end-stage kidney disease (ESKD), likelihood of receiving pre-ESKD care, and likelihood of receiving a transplant. However, few studies have examined whether these same factors are associated with ESKD mortality. In this study, we examined county-level variation in ESKD mortality and identified county-level characteristics associated with this variation. Methods: We identified 1,515,986 individuals (aged 18-84) initiating renal replacement therapy (dialysis or transplant) between 2010 and 2018 using the United States Renal Data System. Among 2,781 counties, we estimated county-level all-cause age-standardized mortality rates (ASMR) among patients with ESKD. We then identified county-level demographic (e.g., % female), socioeconomic (e.g., % unemployed), health care (e.g., % without health insurance), and health behavior (e.g., % current smokers) characteristics associated with ASMR using multivariable hierarchical linear mixed models and quantified the percentage of ASMR variation explained by county-level characteristics. Results: County-level ESKD ASMR ranged from 45 to 1,022 per 1,000 person-years (PY) (mean, 119/1,000 PY). ASMRs were highest in counties located in the Tennessee Valley and Appalachia regions, and lowest in counties located in New England, Pacific Northwest, and southern California. In fully adjusted models, county-level characteristics significantly associated with higher ESKD mortality included a lower percentage of Black residents (-4.94/1,000 PY), lower transplant rate (-4.08/1,000 PY), and higher health care expenditures (5.21/1,000 PY). Overall, county-level characteristics explained 18.9% of variation in ESKD mortality. Conclusions: Counties with high ESKD-related mortality may benefit from targeted and multi-level interventions that combine knowledge from a growing evidence base on the interplay between individual and community-level factors associated with ESKD mortality.