Dialysis Facility Closures in the US From 2018 to 2024: A Serial Cross-Sectional Study

Between 2006 and 2016, the number of US dialysis facilities experienced steady annual growth. Recent data suggest a reversal in this trend. We examined trends in US dialysis facility closures and associated facility- and neighborhood-level characteristics.

Serial cross-sectional study of dialysis facilities from 2018 through 2024.

Dialysis facilities in the United States.

Calendar year; census region; census tract social vulnerability index; rural or urban area designation; racial and ethnic composition; COVID-19 mortality; dialysis facility payor mix, size, and profit status.

Number of dialysis facility closures; temporal change in number of facilities by census tract.

Dialysis facilities listed in the Provider of Services data from Centers for Medicare & Medicaid Services were used to determine openings and closures by quarter. Geocoded dialysis facility data were linked to the American Community Survey, rural urban commuting area codes, and the United States Renal Data System to describe associated facility- and neighborhood-level characteristics of closed facilities, and of census tracts without any remaining dialysis facilities.

We identified 8,343 unique dialysis facilities across 7,222 census tracts from 2018 through 2024. Annual opening-to-closure ratios were 8.9 (2018: 401 openings, 45 closures), 2.7 (2019: 293 openings, 105 closures), 4.3 (2020: 218 openings, 51 closures), 1.5 (2021: 171 openings, 111 closures), 0.6 (2022: 123 openings, 210 closures), 0.5 (2023: 94 openings, 207 closures), and 0.8 (2024: 56 openings,74 closures). Closures exceeded openings between the fourth quarter of 2021 and the first quarter of 2024 (n = 500; 62.2% of all closures during study period). Closed facilities were smaller than the facilities that remained open (median size 58 [IQR, 34-96] for closed vs 112 [IQR, 66-165] for open facilities). Closures were observed more frequently in rural versus urban areas (11.2% vs 9.3%, respectively) and among facilities located in the Midwest versus the West (10.8% vs 7.7%, respectively). Closed facilities had a modestly higher proportion of patients eligible for both Medicaid and Medicare-dual eligibility, a marker of economic disadvantage-than the facilities that remained open (mean proportion of census dual eligible 36.1% vs 34.6%).

Lack of data on patient outcomes.

Nationwide, an increasing number of US dialysis facilities closed between 2018 and 2024, with smaller facilities and rural and Midwest communities disproportionately affected. The patient-level implications of this trend require further study.

Until recently, the number of dialysis facilities in the United States was increasing, but this trend may have reversed in 2022. This study assessed whether dialysis facility closures were relatively more common in rural or socially vulnerable areas. It found a drastic increase in numbers of closures and a decrease in number of openings across the United States starting in late 2021, with closures disproportionately affecting smaller facilities, rural areas, and the Midwest. Closures may reflect a change in demand for dialysis, but because prior data have indicated dialysis facility closures disrupt patient care, this trend and its effect on persons with complex medical needs requires attention by nephrologists and policymakers.