1. 2015 ANNUAL DATA REPORT V OLUME 2: E ND -S TAGE R ENAL D ISEASE Chapter 14: End-of-life Care for Patients with End-Stage Renal Disease: 2000-2012

2. Table 14.1 Characteristics of decedents with ESRD by death year, 2000-2012 Vol 2, ESRD, Ch 142 (Continue on the next slide) 2000200120022003200420052006200720082009201020112012Total n72,92677,12479,80482,69684,34786,10787,85387,96788,83890,35591,10791,96289,511 1,110,5 97 %6.66.97.27.47.67.87.9 8.08.18.28.38.1100.0 Age (mean) 67.5 (13.7) 67.5 (13.8) 67.8 (13.9) 67.9 (13.8) 68.1 (13.8) 68.4 (13.8) 68.4 (13.8) 68.5 (13.8) 68.75 13.7) 68.6 (13.7) 68.9 (13.6) 69.0 (13.5) 69.1 (13.4) 68.4 (13.7) Age Category 0-190.2 0.1 0.20.1 0.2 20-446.86.6 6.25.95.85.65.55.25.14.74.64.55.6 45-6428.829.229.029.629.729.530.130.029.930.330.130.230.029.7 65-7429.128.427.927.327.026.625.9 26.426.626.7 27.727.1 75-8427.627.828.1 28.328.428.228.027.526.926.726.626.127.5 ≥857.47.88.38.78.99.610.110.610.911.111.611.8 10.0 Race Native American1.21.1 1.21.1 1.01.1 Asian2.8 2.93.0 3.23.33.43.33.5 3.7 3.3 Black28.228.328.028.228.428.127.727.527.427.226.826.5 27.6 White65.9 66.165.765.466.166.967.167.367.468.068.268.366.8 Unknown0.30.2 0.30.2 0.1 0.2 Other1.7 1.8 1.20.90.80.7 0.6 0.41.1 Hispanic No71.275.178.179.881.382.483.384.184.4 84.684.584.381.6 Yes8.39.09.49.810.010.310.4 10.711.011.111.611.710.4 Unknown1.51.11.00.80.70.60.50.40.30.2 0.1 0.5 Missing19.014.811.69.68.06.85.95.14.74.44.13.83.97.5

3. Vol 2, ESRD, Ch 143 Table 14.1 Characteristics of decedents with ESRD by death year, 2000-2012 (Continued) Data Source: Special analyses, USRDS ESRD Database. Denominator is all decedents. Sex Male52.252.452.653.053.754.054.254.755.155.755.856.256.354.4 Female47.847.647.447.046.346.045.845.344.844.2 43.843.745.6 Last Treatment Modality Hemodialysis86.387.188.088.388.588.688.889.189.088.988.888.287.888.3 Peritoneal Dialysis7.36.76.15.85.65.14.94.4 4.24.34.65.05.2 Transplant4.64.5 4.44.74.85.0 5.4 5.75.85.0 Missing1.91.71.5 1.61.51.6 1.5 1.41.5 Medicare Parts A&B as primary payer during last 3 months of life Yes57.460.664.366.667.868.568.167.165.865.265.065.165.565.3

4. Data Source: Special analyses, USRDS ESRD Database. Denominator is all decedents with Medicare Parts A and B throughout the last 90 days of life. Includes hospital stays in both short and long stay hospitals. Figure 14.1 Hospital admission during the last 90 days of life among Medicare beneficiaries with ESRD, 2000-2012 Vol 2, ESRD, Ch 144

5. Data Source: Special analyses, USRDS ESRD Database. Denominator is all decedents with Medicare Parts A and B throughout the last 90 days of life who were admitted to the hospital at least once. Includes hospital stays in both short and long stay hospitals. Explanation of box plot: The lower border of the box is the first quartile and the upper border is the third quartile of the distribution, the length of the box is the interquartile range and the line in the middle of the box is the median value. The whiskers (vertical lines above and below each box) extend from the lowest value of the distribution that is ≥ the first quartile minus 1.5 times the interquartile range at the bottom to the highest value of the distribution that is ≤ the third quartile plus 1.5 times the interquartile range at the top. Values outside this range (outliers) are not plotted. Figure 14.2 Days spent in the hospital during the last 90 days of life among Medicare beneficiaries with ESRD, 2000-2012 Vol 2, ESRD, Ch 145

6. Data Source: Special analyses, USRDS ESRD Database. Denominator is all decedents with Medicare Parts A and B throughout the last 90 days of life. ICU admission was identified using ICU revenue center codes in Medicare Institutional claims. Figure 14.3 Days spent in the hospital during the last 90 days of life among Medicare beneficiaries with ESRD, 2000-2012 Vol 2, ESRD, Ch 146 (a) ICU admission by year, overall

7. Figure 14.3 Days spent in the hospital during the last 90 days of life among Medicare beneficiaries with ESRD, 2000-2012 Vol 2, ESRD, Ch 147 (b) ICU admission by age Data Source: Special analyses, USRDS ESRD Database. Denominator is all decedents with Medicare Parts A and B throughout the last 90 days of life. ICU admission was identified using ICU revenue center codes in Medicare Institutional claims.

8. Figure 14.3 Days spent in the hospital during the last 90 days of life among Medicare beneficiaries with ESRD, 2000-2012 Vol 2, ESRD, Ch 148 (c) ICU admission by race Data Source: Special analyses, USRDS ESRD Database. Denominator is all decedents with Medicare Parts A and B throughout the last 90 days of life. ICU admission was identified using ICU revenue center codes in Medicare Institutional claims.

9. Figure 14.3 Days spent in the hospital during the last 90 days of life among Medicare beneficiaries with ESRD, 2000-2012 Vol 2, ESRD, Ch 149 (d) ICU admission by ethnicity

10. Data Source: Special analyses, USRDS ESRD Database. Denominator is all decedents with Medicare Parts A and B throughout the last 90 days of life. ICU admission was identified using ICU revenue center codes in Medicare Institutional claims. Figure 14.3 Days spent in the hospital during the last 90 days of life among Medicare beneficiaries with ESRD, 2000-2012 Vol 2, ESRD, Ch 1410 (e) ICU admission by sex

11. Data Source: Special analyses, USRDS ESRD Database. Denominator is all decedents with Medicare Parts A and B throughout the last 90 days of life. ICU admission was identified using ICU revenue center codes in Medicare Institutional claims. Figure 14.3 Days spent in the hospital during the last 90 days of life among Medicare beneficiaries with ESRD, 2000-2012 Vol 2, ESRD, Ch 1411 (f) ICU admission by modality

12. Figure 14.4 Intensive procedures during the last 90 days of life among Medicare beneficiaries with ESRD overall, and by age, race, ethnicity, sex, and modality, 2000-2012 Vol 2, ESRD, Ch 1412 (a) Intensive procedures and mechanical ventilation by year, overall Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life. Intensive procedures were identified by ICD-9 procedure code search of Medicare Institutional claims from short and long stay hospitals. The yellow line in panel (a) denotes the percentage of patients who were intubated or received mechanical ventilation.

13. Figure 14.4 Intensive procedures during the last 90 days of life among Medicare beneficiaries with ESRD overall, and by age, race, ethnicity, sex, and modality, 2000-2012 Vol 2, ESRD, Ch 1413 (b) Intensive procedures by age Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life. Intensive procedures were identified by ICD-9 procedure code search of Medicare Institutional claims from short and long stay hospitals.

14. Figure 14.4 Intensive procedures during the last 90 days of life among Medicare beneficiaries with ESRD overall, and by age, race, ethnicity, sex, and modality, 2000-2012 Vol 2, ESRD, Ch 1414 (c) Intensive procedures by race Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life. Intensive procedures were identified by ICD-9 procedure code search of Medicare Institutional claims from short and long stay hospitals.

15. Figure 14.4 Intensive procedures during the last 90 days of life among Medicare beneficiaries with ESRD overall, and by age, race, ethnicity, sex, and modality, 2000-2012 Vol 2, ESRD, Ch 1415 (d) Intensive procedures by ethnicity Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life. Intensive procedures were identified by ICD-9 procedure code search of Medicare Institutional claims from short and long stay hospitals.

16. Figure 14.4 Intensive procedures during the last 90 days of life among Medicare beneficiaries with ESRD overall, and by age, race, ethnicity, sex, and modality, 2000-2012 Vol 2, ESRD, Ch 1416 (e) Intensive procedures by sex Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life. Intensive procedures were identified by ICD-9 procedure code search of Medicare Institutional claims from short and long stay hospitals.

17. Figure 14.4 Intensive procedures during the last 90 days of life among Medicare beneficiaries with ESRD overall, and by age, race, ethnicity, sex, and modality, 2000-2012 Vol 2, ESRD, Ch 1417 (f) Intensive procedures by modality Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life. Intensive procedures were identified by ICD-9 procedure code search of Medicare Institutional claims from short and long stay hospitals.

18. Figure 14.5 Inpatient deaths among Medicare beneficiaries with ESRD overall, and by age, race, ethnicity, sex, and modality, 2000-2012 Vol 2, ESRD, Ch 1418 (a) Inpatient deaths by year, overall Data Source: Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life. Includes deaths occurring in short and long stay hospitals.

19. Figure 14.5 Inpatient deaths among Medicare beneficiaries with ESRD overall, and by age, race, ethnicity, sex, and modality, 2000-2012 Vol 2, ESRD, Ch 1419 (b) Inpatient deaths by age Data Source: Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life. Includes deaths occurring in short and long stay hospitals.

20. Figure 14.5 Inpatient deaths among Medicare beneficiaries with ESRD overall, and by age, race, ethnicity, sex, and modality, 2000-2012 Vol 2, ESRD, Ch 1420 (c) Inpatient deaths by race Data Source: Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life. Includes deaths occurring in short and long stay hospitals.

21. Figure 14.5 Inpatient deaths among Medicare beneficiaries with ESRD overall, and by age, race, ethnicity, sex, and modality, 2000-2012 Vol 2, ESRD, Ch 1421 (d) Inpatient deaths by ethnicity Data Source: Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life. Includes deaths occurring in short and long stay hospitals.

22. Figure 14.5 Inpatient deaths among Medicare beneficiaries with ESRD overall, and by age, race, ethnicity, sex, and modality, 2000-2012 Vol 2, ESRD, Ch 1422 (e) Inpatient deaths by sex Data Source: Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life. Includes deaths occurring in short and long stay hospitals.

23. Figure 14.5 Inpatient deaths among Medicare beneficiaries with ESRD overall, and by age, race, ethnicity, sex, and modality, 2000-2012 Vol 2, ESRD, Ch 1423 (f) Inpatient deaths by modality Data Source: Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life. Includes deaths occurring in short and long stay hospitals.

24. Figure 14.6 Dialysis discontinuation before death among decedents overall, and by age, race, ethnicity, sex, and modality, 2000-2012 Vol 2, ESRD, Ch 1424 (a) Dialysis discontinuation by year, overall Data Source: Special analyses, USRDS ESRD Database. Denominator population is all patients with complete data on dialysis discontinuation from the CMS Death Notification form (CMS 2746).

25. Figure 14.6 Dialysis discontinuation before death among decedents overall, and by age, race, ethnicity, sex, and modality, 2000-2012 Vol 2, ESRD, Ch 1425 (b) Dialysis discontinuation by age Data Source: Special analyses, USRDS ESRD Database. Denominator population is all patients with complete data on dialysis discontinuation from the CMS Death Notification form (CMS 2746).

26. Figure 14.6 Dialysis discontinuation before death among decedents overall, and by age, race, ethnicity, sex, and modality, 2000-2012 Vol 2, ESRD, Ch 1426 (c) Dialysis discontinuation by race Data Source: Special analyses, USRDS ESRD Database. Denominator population is all patients with complete data on dialysis discontinuation from the CMS Death Notification form (CMS 2746).

27. Figure 14.6 Dialysis discontinuation before death among decedents overall, and by age, race, ethnicity, sex, and modality, 2000-2012 Vol 2, ESRD, Ch 1427 (d) Dialysis discontinuation by ethnicity Data Source: Special analyses, USRDS ESRD Database. Denominator population is all patients with complete data on dialysis discontinuation from the CMS Death Notification form (CMS 2746).

28. Figure 14.6 Dialysis discontinuation before death among decedents overall, and by age, race, ethnicity, sex, and modality, 2000-2012 Vol 2, ESRD, Ch 1428 (e) Dialysis discontinuation by sex Data Source: Special analyses, USRDS ESRD Database. Denominator population is all patients with complete data on dialysis discontinuation from the CMS Death Notification form (CMS 2746).

29. Figure 14.6 Dialysis discontinuation before death among decedents overall, and by age, race, ethnicity, sex, and modality, 2000-2012 Vol 2, ESRD, Ch 1429 (f) Dialysis discontinuation by modality Data Source: Special analyses, USRDS ESRD Database. Denominator population is all patients with complete data on dialysis discontinuation from the CMS Death Notification form (CMS 2746).

30. Figure 14.7 Hospice utilization at the time of death among Medicare beneficiaries with ESRD overall, and by age, race, ethnicity, sex, modality, and whether dialysis was discontinued, 2000-2012 Vol 2, ESRD, Ch 1430 (a) Hospice utilization by year, overall Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life. Receipt of hospice care at the time of death was defined as having a claim in the Hospice SAF on or after the date of death or Discharge Status from hospice=40, 41 or 42.

31. Figure 14.7 Hospice utilization at the time of death among Medicare beneficiaries with ESRD overall, and by age, race, ethnicity, sex, modality, and whether dialysis was discontinued, 2000-2012 Vol 2, ESRD, Ch 1431 (b) Hospice utilization by age Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life. Receipt of hospice care at the time of death was defined as having a claim in the Hospice SAF on or after the date of death or Discharge Status from hospice=40, 41 or 42.

32. Figure 14.7 Hospice utilization at the time of death among Medicare beneficiaries with ESRD overall, and by age, race, ethnicity, sex, modality, and whether dialysis was discontinued, 2000-2012 Vol 2, ESRD, Ch 1432 (c) Hospice utilization by race Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life. Receipt of hospice care at the time of death was defined as having a claim in the Hospice SAF on or after the date of death or Discharge Status from hospice=40, 41 or 42.

33. Figure 14.7 Hospice utilization at the time of death among Medicare beneficiaries with ESRD overall, and by age, race, ethnicity, sex, modality, and whether dialysis was discontinued, 2000-2012 Vol 2, ESRD, Ch 1433 (d) Hospice utilization by ethnicity Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life. Receipt of hospice care at the time of death was defined as having a claim in the Hospice SAF on or after the date of death or Discharge Status from hospice=40, 41 or 42.

34. Figure 14.7 Hospice utilization at the time of death among Medicare beneficiaries with ESRD overall, and by age, race, ethnicity, sex, modality, and whether dialysis was discontinued, 2000-2012 Vol 2, ESRD, Ch 1434 (e) Hospice utilization by sex Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life. Receipt of hospice care at the time of death was defined as having a claim in the Hospice SAF on or after the date of death or Discharge Status from hospice=40, 41 or 42.

35. Figure 14.7 Hospice utilization at the time of death among Medicare beneficiaries with ESRD overall, and by age, race, ethnicity, sex, modality, and whether dialysis was discontinued, 2000-2012 Vol 2, ESRD, Ch 1435 (f) Hospice utilization by modality Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life. Receipt of hospice care at the time of death was defined as having a claim in the Hospice SAF on or after the date of death or Discharge Status from hospice=40, 41 or 42.

36. Figure 14.7 Hospice utilization at the time of death among Medicare beneficiaries with ESRD overall, and by age, race, ethnicity, sex, modality, and whether dialysis was discontinued, 2000-2012 Vol 2, ESRD, Ch 1436 (g) Hospice utilization by whether patients discontinued dialysis before death Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life. Receipt of hospice care at the time of death was defined as having a claim in the Hospice SAF on or after the date of death or Discharge Status from hospice=40, 41 or 42.

37. Figure 14.8 Costs in the (a) last 30 days of life, and (b) last 7 days of life in relation to timing of hospice care, 2012 Vol 2, ESRD, Ch 1437 (a) Last 30 days of life Data Source: Special analyses, USRDS ESRD Database. Denominator population is all decedents with Medicare Parts A and B throughout the last 90 days of life exclusive of those patients without any costs during the last 30 days of life and those with negative costs. Date of the first claim in the Hospice SAF (HCFASAF=H) within the last 90 days of life is taken as the date of first receipt of hospice services. Timing of hospice referral in relation to death was categorized by quartile (1st quartile 0-2 days, 2nd quartile 3-5 days, 3rd quartile 6-14 days and 4th quartile 15-90 days). Explanation of box plot: the lower border of the box is the first quartile and the upper border is the third quartile of the distribution, the length of the box is the interquartile range, and the line in the middle of the box is the median value. The whiskers extend from the lowest value of the distribution that is ≥ the first quartile minus 1.5 times the interquartile range at the bottom to the highest value of the distribution that is ≤ the third quartile plus 1.5 times the interquartile range at the top. Values outside this range (outliers) are not plotted. (b) Last 7 days of life