Patient Health Outcomes following Dialysis Facility Closures in the United States.

BACKGROUND: Ongoing changes to reimbursement of United States dialysis care may increase the risk of dialysis facility closures. Closures may be particularly detrimental to the health of patients receiving dialysis, who are medically complex and clinically tenuous. METHODS: We used two separate analytic strategies-one using facility-based matching and the other using propensity score matching-to compare health outcomes of patients receiving in-center hemodialysis at United States facilities that closed with outcomes of similar patients who were unaffected. We used negative binomial and Cox regression models to estimate associations of facility closure with hospitalization and mortality in the subsequent 180 days. RESULTS: We identified 8386 patients affected by 521 facility closures from January 2001 through April 2014. In the facility-matched model, closures were associated with 9% higher rates of hospitalization (relative rate ratio [RR], 1.09; 95% confidence interval [95% CI], 1.03 to 1.16), yielding an absolute annual rate difference of 1.69 hospital days per patient-year (95% CI, 0.45 to 2.93). Similarly, in a propensity-matched model, closures were associated with 7% higher rates of hospitalization (RR, 1.07; 95% CI, 1.00 to 1.13; P=0.04), yielding an absolute rate difference of 1.08 hospital days per year (95% CI, 0.04 to 2.12). Closures were associated with nonsignificant increases in mortality (hazard ratio [HR], 1.08; 95% CI, 1.00 to 1.18; P=0.05 for the facility-matched comparison; HR, 1.08; 95% CI, 0.99 to 1.17; P=0.08 for the propensity-matched comparison). CONCLUSIONS: Patients affected by dialysis facility closures experienced increased rates of hospitalization in the subsequent 180 days and may be at increased risk of death. This highlights the need for effective policies that continue to mitigate risk of facility closures.

Consolidation in dialysis Markets-Causes, consequences, and the role of policy.

The dialysis industry is one of the most highly concentrated healthcare sectors in the United States. Despite decades of growth in the number of patients with end-stage renal disease and in the size of dialysis markets, two large dialysis organizations currently care for more than two-thirds of the dialysis population. Economies of scale, bargaining leverage with suppliers and private insurers, barriers to entry, and government regulations have contributed to highly concentrated dialysis markets by conferring advantages to larger organizations. Consolidated dialysis markets have coincided with both positive and negative trends in healthcare costs and outcomes. Costs per patient receiving dialysis have grown at a slower rate than per capita Medicare costs, while access to dialysis care remains available across a wide socioeconomic range. Mortality rates have declined despite a sicker dialysis patient population. Yet, concerns remain about the cost and quality of dialysis care. Evidence suggests that chain ownership, for profit status, and less market competition may negatively impact health outcomes. Future policies and innovations involving kidney health may temporarily disrupt consolidation. However, if the underlying mechanisms that contributed to past consolidation persist, dialysis markets may remain highly concentrated over the long term.