Care Continuity, Nephrologists' Dialysis Facility Preferences, and Outcomes

Area of Science:

• Nephrology
• Health Services Research
• Health Equity

Background:

• Patients initiating dialysis may prioritize continuity of care by choosing their nephrologist's primary facility, regardless of facility quality.
• This practice can lead to suboptimal dialysis start experiences, particularly for patients from minoritized racial and ethnic groups.

Purpose of the Study:

• To investigate the prevalence of dialysis initiation at nephrologists' primary facilities.
• To analyze downstream health outcomes and racial disparities associated with dialysis start quality.
• To examine the influence of facility quality and proximity on patient choices.

Main Methods:

• A cohort study utilizing Medicare administrative data from US freestanding dialysis facilities (2015-2020).
• Analysis included 143,776 adult patients with fee-for-service Medicare initiating dialysis.
• Multivariable regression models assessed associations between facility quality (5-star ratings), proximity, and outcomes like mortality and hospitalizations, controlling for hospital service area fixed effects.

Main Results:

• Dialysis starts at nephrologists' primary facilities decreased as facility quality increased.
• Higher quality primary facilities were associated with more high-quality starts and fewer hospitalizations.
• Black patients were less likely than White patients to start dialysis at high-quality facilities and less likely to have nephrologists with high-quality primary facilities.

Conclusions:

• Dialysis initiation at low-quality primary facilities is common, leading to worse patient outcomes.
• Significant racial disparities exist, with Black patients disproportionately starting dialysis at lower-quality facilities.
• Policy interventions promoting access to high-quality dialysis facilities are needed to mitigate these disparities.