We prospectively surveyed the 156 dialysis centers in Network 5 (MD, VA, WV, DC) for end-stage renal disease (ESRD) patients admitted to or begun on dialysis in nursing homes during a 21-month period (April 1, 1990 to December 31, 1991). In addition to this incidence data, information on patient demographics, social characteristics, pre-existent illnesses, and functional capacity (measured by activity of daily living [ADL] scores) was obtained. One hundred thirty-two centers (close to 90% of Network 5's approximately 9,000 patients) responded to the survey. Outcome data were gathered throughout the 21-month period and the subsequent 5 months. Seventy-three centers dialyzed 228 such patients during the 18-month period. Five centers that were located in the same building as a nursing home cared for 67 patients. The 228 patients, aged 17 to 101 years, were older (65.50 years ± 14.2 [SD] v 53.7 ± 16.4 years), and disproportionately female (62.2% v 48.3%), white (46.5% v 37.4%), and diabetic (57.9% v 29%) compared with the general network ESRD population (P <0.05). On admission to the nursing home 47% of patients had organic heart disease, 35% had an organic brain syndrome, 22% had cerebrovascular diseases, 19% had amputations, and 18% were blind. The mean admission ADL score was 8.1 ± 5.2 (maximum function, 18) and the patients did not differ regarding age, sex, race, or diabetes. Forty-three percent of patients lived alone or in sheltered housing before being placed in the nursing home. The modalities used (hemodialysis, 87.3% of patients; peritoneal dialysis, 12.7% of patients) were similar to the network (hemodialysis, 84% of patients; peritoneal dialysis, 16% of patients). One referral center cared for 73% of the peritoneal dialysis patients. Analysis of outcome data for 216 of 228 patients followed for up to 5 months after the close of entry into the study showed that 150 had died (mean survival, 6.2 ± 5.9 months), 34 were discharged from the nursing home (mean stay, 3.5 ± 3.9 months), 44 remain in a nursing home, and 17 were alive outside the nursing home. Survival rates at 3, 6, and 12 months were 74%, 56%, and 42%, respectively. In a Cox analysis, mortality was significantly worse for patients older than 75 years, those with ADL scores ≤ 8, and those receiving peritoneal rather than hemodialysis (P <0.01). Race, sex, diabetes, and prior duration of dialysis did not affect dialysis survival. A significant number of ESRD patients require nursing home admission, but our estimate of the prevalence rate in Network 5 for patients aged 65 years or older is less than 2% compared with the 4% to 5% prevalence rate of nursing home residence for the general US population who are aged 65 years or older. Since ESRD patients are not likely to be healthier or to have better social support structures than the general population, this finding suggests that there are impediments to nursing home placement, such as financial concerns, transportation problems, and nursing home staff fears of ESRD patients. White race, female gender, diabetes, and fragile living situations may be risks for nursing home placement. Mortality is high, particularly for older, less functional patients. © 1993, National Kidney Foundation, Inc. All rights reserved. All rights reserved.
