Variation in Dialysis Quality Measures by Facility, Neighborhood, and Region

Abstract

Background We examined whether dialysis facility characteristics, neighborhood demographics, and region are associated with Centers for Medicare and Medicaid Services (CMS) dialysis facility quality measures in order to determine the most important targets for intervention. Methods We linked US census data to the CMS Dialysis Compare File which contains information for facility outcomes for all CMS certified dialysis facilities in 2007 (n=5616). We then used linear and logistic regression to characterize the association between dialysis facility quality—worse than expected patient survival, and the proportion of individuals in a facility achieving dialysis adequacy (urea reduction rate >65) or target hemoglobin (10<Hgb<12g/dL)—and dialysis facility characteristics, neighborhood demographics, and region. Results Only an increasing proportion of African-Americans in the neighborhood is consistently associated with worse dialysis facility outcomes, even after controlling for neighborhood poverty. Facilities with the highest proportion of African-Americans in the neighborhood had worse patient survival (OR 4.6, 95% CI [2.8, 7.6]), were less likely to have adequate dialysis (β −1.4, 95% CI [−2.3, −0.6]), and achieve targeted hemoglobin (β −3.1, 95% CI [−4.7, −1.6]) compared to those with the lowest proportion. No other predictor—facility, neighborhood or region—was consistently associated with dialysis facility quality. Conclusions The proportion of African-Americans in the dialysis facility neighborhood is strongly and consistently associated with lower facility quality. Quality improvement efforts are particularly needed for dialysis facilities in minority communities.

Association between Freestanding Dialysis Facility Size and Medicare Quality Incentive Program Performance Scores

“…Earlier research has shown that the facilities in the Midwest perform better than those in the South [11]. In our study, facilities in the South and Northeast performed better than those in the West.…”

“…The previous studies have reported that for-profit facilities demonstrate better patient urea reduction ratio [11,[32][33][34] and Hgb levels [33,35]. Therefore, we anticipated higher QIP scores among for-profit facilities.…”

“…While studies report on the association between facility and ecological factors and attainment of target clinical measures including Hgb level, urea reduction ratio, vascular access, and albumin level, [11,32,33], there has been little examination of the association between ecological and clinical factors and QIP score. This is because QIP is a relatively new initiative, implemented in 2012.…”

“…Such facilities are mostly rural, remote, low-volume, and low profit margin [6,8,9]. Previously, a study has also shown facilities located in the poor socioeconomic neighborhood and rural areas showed poor performance and health outcomes [10][11][12]. Reduced payments under the bundled payment reform were expected to increase the financial constraints among small facilities.…”

“…Further, little data exist on the association between size and facility performance [14]. The existing research does not take into account patient factors, which are the known covariates of care quality and health outcomes [11,[15][16][17][18][19]. Therefore, we examined the association between freestanding dialysis facility size and QIP scores, after adjusting for multilevel covariates including patients, neighborhood, and facility factors using a nationally representative sample of freestanding dialysis facilities.…”