Residential Area Life Expectancy: Association With Outcomes and Processes of Care for Patients With ESRD in the United States.

BACKGROUND: The effects of underlying noncodified risks are unclear on the prognosis of patients with end-stage renal disease (ESRD). We aimed to evaluate the association of residential area life expectancy with outcomes and processes of care for patients with ESRD in the United States.

STUDY DESIGN: Retrospective cohort study.

SETTING & PARTICIPANTS: Adult patients with incident ESRD between 2006 and 2013 recorded in the US Renal Data System (n=606,046).

PREDICTOR: The primary exposure was life expectancy in the patient's residential county estimated by the Institute for Health Metrics and Evaluation.

OUTCOMES: Death, placement on the kidney transplant wait list, living and deceased donor kidney transplantation, and posttransplantation graft loss.

RESULTS: Median life expectancies of patients' residences were 75.6 (males) and 80.4 years (females). Compared to the highest life expectancy quintile and adjusted for demographic factors, disease cause, and multiple comorbid conditions, the lowest quintile had adjusted HRs for mortality of 1.20 (95% CI, 1.18-1.22); placement onto the waiting list, 0.68 (95% CI, 0.67-0.70); living donor transplantation, 0.53 (95% CI, 0.51-0.56); posttransplantation graft loss, 1.35 (95% CI, 1.27-1.43); and posttransplantation mortality, 1.29 (95% CI, 1.19-1.39). Patients living in areas with lower life expectancy were less likely to be informed about transplantation, be under the care of a nephrologist, or receive an arteriovenous fistula as the initial dialysis access. Results remained consistent with additional adjustment for zip code-level median income, population size, and urban-rural locality.

LIMITATIONS: Potential residual confounding and attribution of effects to individuals based on residential area-level data.

CONCLUSIONS: Residential area life expectancy, a proxy for socioeconomic, environmental, genetic, and behavioral factors, was independently associated with mortality and process-of-care measures for patients with ESRD. These results emphasize the underlying effect on health outcomes of the environment in which patients live, independent of patient-level factors. These findings may have implications for provider assessments.