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Increasing the Value of End-of-Life Care for End-Stage Renal Disease Patients: The Role of Palliative Care, Advance Directives and Healthcare Value Measurement



End-Stage Renal Disease (ESRD) patients frequently receive intensive end-of-life care that may not improve the quality of experience for patients and their families. This dissertation seeks to improve the value of ESRD end-of-life care by filling three key gaps in the literature: 1) the current state of value measurement in medical literature, 2) resource use implications of providing inpatient palliative care for ESRD patients, and 3) racial disparities in advance directive completion exist among nursing-home bound ESRD patients.


The use of value measurement in medical literature was analyzed by reviewing medical, health policy and health economics journals for frequency of value measurement term occurence.

The association of inpatient palliative care with difference in length of stay and hospital costs among Medicare beneficiaries with ESRD who had a hospitalization in 2012 and 2013 was assessed with propensity score matching, and generalized linear modeling of data from the United States Renal Data System (USRDS).

Racial disparities in advance directive completion among ESRD patients residing in a nursing home were evaluated using data from USRDS, Medicare Claims, and the CMS Minimum Data Set.


Use of economic methods of value measurement (cost effectiveness and cost utility analysis) is recommended as a framework for generating medical research that facilitates prioritizing healthcare services according to value.

Among ESRD patients who died in the hospital, inpatient palliative care was associated with shorter hospitalizations and lower costs. For those who survived to discharge, inpatient palliative care was associated with no difference in length of stay, and higher hospitalization costs; which may be offset by increased hospice use and fewer re-admissions in the 30-day post-discharge period.

The prevalence of advance directive completion was low among ESRD patients of all races. Patients of Non-Hispanic black and minority races were less likely to complete all advance directive types than Non-Hispanic whites.

Conclusions: The value of ESRD end-of-life care would be improved by systematically incorporating value measurement into medical research, expanding the use of inpatient palliative care for patients nearing the end of life, and increasing the use of advance directives among all ESRD patients.

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