Facility Size, Race and Ethnicity, and Mortality for In-Center Hemodialysis

Abstract

The association between dialysis facility size and mortality for patients undergoing hemodialysis remains largely unclear, and whether the relationship differs by race and ethnicity or among high-risk subgroups is not known. Using data from the USRDS, we analyzed mortality rates in 385,074 incident patients ages$18 years who received in-center hemodialysis at 4633 dialysis facilities between 2003 and 2009. Facilities were categorized by the number of hemodialysis stations (1-5, 6-10, 11-15, 16-20, 21-25, 26-30, 31-35, 36-45, 46-60, and $61 stations). We found significantly higher mortality associated with facilities comprising #15 stations, and within this group, mortality increased as the number of stations decreased. The association with increased mortality was weaker for facilities with 16-30 stations, but .30 stations offered no additional survival benefit. The association between increased mortality and facilities with #15 stations was stronger for racial minorities and patients with diabetes or cardiovascular diseases. After adjustments, blacks had a 78% greater 1-year mortality risk in facilities with one to five stations, whereas whites had only a 26% greater risk. Notably, other patient-related events remained comparable across the categories assessed. In summary, these data suggest that hemodialysis care at small facilities associates with a significant increase in mortality that is only partially explained by measured patient case mix, other well defined facility characteristics, and geographic region. Future studies should investigate differences in processes of care and practices among hemodialysis facilities of different sizes.

Association of peripheral arterial disease with all-cause and cardiovascular mortality in hemodialysis patients: a meta-analysis

“…A review reported that the annual crude death rate was in the range of 9.0%–10.2% for dialysis populations in Japan [2]. Yan et al [3] followed up 385,074 HD patients and reported that the one-year mortality was 19.8% and the five-year mortality was 43.0%. The high mortality of HD may be due to the plenty of vascular complications, such as vascular calcification [4] and atherosclerosis [5].…”

Facility size and mortality in hospital‐based and freestanding haemodialysis units: A nationwide retrospective cohort study

“…Previous studies showed that patients in smaller HD facilities have either more comorbidities or worse pre‐ESRD care . In our cohort, patients treated in smaller HD units displayed more unfavourable prognostic factors.…”

“…This threshold size is much higher than that reported by Yan et al Notably, the size of HD facilities in Taiwan is larger than that in the United States. In the study of Yan et al , only 7.8% of patients received HD in facilities with ≥31 stations . In the present study, 13.9% and 3.9% of patients in freestanding HD units were treated in facilities with 31–45 and ≥ 45 stations, respectively.…”

“…In the present study, 13.9% and 3.9% of patients in freestanding HD units were treated in facilities with 31–45 and ≥ 45 stations, respectively. Furthermore, RN, licensed practical nurses (LPN), and unlicensed patient care technicians provide direct care during HD in the United States, and there are higher RN‐ and LPN‐to‐patient ratios in small facilities . By contrast, only RNs are allowed to perform HD to patients in Taiwan.…”

“…Furthermore, RN, licensed practical nurses (LPN), and unlicensed patient care technicians provide direct care during HD in the United States, and there are higher RN-and LPNto-patient ratios in small facilities. 14 By contrast, only RNs are allowed to perform HD to patients in Taiwan. Therefore, the advantage of large facility size in Taiwan may not be offset by the low RN-to-patient ratio in large HD units.…”