Closure of in-center dialysis facilities increases the risk of hospitalization among patients with end-stage kidney disease (ESKD) who attended those facilities relative to similar patients not affected by facility closures, new research suggests.
“Patients with ESKD on dialysis often have multiple comorbidities, and they are frequently in and out of the hospital anyway, so their acuity of illness might make them more dependent on the frequent interactions they have with healthcare providers during dialysis,” Kevin Erickson, MD, assistant professor of medicine, Baylor College of Medicine, Houston, Texas, told Medscape Medical News.
“So our hypothesis was that when these interactions are disrupted, patients might be worse off. And while the increase we saw in hospitalizations after closures was modest, I think it was meaningful because the frequency with which these patients are already hospitalized makes this relevant,” he added.
The study was published online October 4 in the Journal of the American Society of Nephrology.
Are Closures Uncommon or Not?
As Erickson noted, reimbursement for dialysis centers is constantly changing. In the period analyzed (January 2001 to April 2014), there was a decrease in the reimbursement allotted for dialysis centers over time. More recently, there has been an increase in payments to facilities, so reimbursement can work in both directions, he pointed out.
Nevertheless, Erickson cautioned that changes to overall payment programs — including a national pay-for-performance program for dialysis facilities initiated in 2010 — along with the Advancing American Kidney Health Initiative (AAKHI) in 2019 have fueled concerns that some dialysis facilities, especially those that serve rural communities and care for vulnerable patient groups, would be at high risk of closing.
“Fortunately, closures are pretty uncommon right now, but if they become more common, it will be important to keep an eye on this [and what it] might mean for patients,” Erickson said.
One way of preventing closures would be to ensure that dialysis centers caring for the sickest patients are not disadvantaged economically by any new payment incentive programs, he added.
Asked for comment on the findings, Jay Wish, MD, professor of clinical medicine, Indiana University, Bloomington, disagreed with Erickson that dialysis facility closures are uncommon.
“Based on the current payer mix, facilities are closing all the time because Medicaid margins are negative and, unless you have commercial payers, you really can’t run a financially healthy facility,” he told Medscape Medical News.
Indeed, Wish has personally experienced this, as the medical director of one such facility in Indiana that was closed because they could not make any money based on the payer mix at the time.
“So we know that this happens,” he emphasized.
The other big contributor to the unprofitability of some dialysis facility centers is the AAKHI initiative to try and increase home dialysis, said Wish.
USRDS Data: Patients More Likely to Miss Treatments if Facilities Closed
For their study, Erickson and colleagues used data from the United States Renal Data System (USRDS) to identify all patients receiving in-center hemodialysis in the United States between January 2001 and April 2014, along with dialysis facility closures.
Over this time, 8386 patients were affected by 521 dialysis facility closures.
The researchers used two separate analytic strategies — a facility-based matching analysis and a propensity-score matching analysis — to compare health outcomes of patients receiving hemodialysis at a facility that closed over the subsequent 180 days with outcomes of similar patients unaffected by facility closures.
Based on the facility-matched analysis, in-center dialysis closures were associated with a 9% higher hospitalization rate or an absolute annual rate of an additional 1.69 days in hospital per patient per year. In the propensity-score matched model, closures were associated with a slightly lower 7% increase in hospitalization rates or an absolute difference of an additional 1.08 days in hospital per patient per year, as Erickson and colleagues report.
Patients affected by in-center dialysis facility closures also had a slightly higher mortality rate than those unaffected by facility closures, although the difference — at between 8% and 9% depending on the model used — was of borderline significance (P = .05), they add.
“Patients at closed facilities were more likely to miss treatments; 42% of patients affected by closures missed at least one treatment in the month of closure compared with 27% of patients who were not affected,” the authors observe.
Loss to follow-up was rare among all patients, although it was slightly higher among patients affected by closures at 0.2% versus 0% for patients not affected by facility closures.
Interestingly, the need for hospitalization was actually more frequent among patients who went on to other dialysis facilities with the same owner compared with to those who attended a dialysis facility with a new owner, although again, the difference between the two groups was not significant.
“Our thought was that perhaps if patients stayed in the same chain of facilities, there would be less of a disruption,” Erickson observed. “[But this finding] suggests that patients may not benefit from the continuity associated with remaining within the same chain.”
Closures were also more closely associated with higher mortality rates among patients who left a hospital-based facility compared with those who left a free-standing facility (P = .004).
Drive to Home Dialysis a Contributor to Closure of Dialysis Centers
Wish expanded on his comments as to how the AAKHI drive to home dialysis is contributing to the closure of dialysis centers.
“What this initiative is saying is that everybody is a candidate for home dialysis so no matter what your particular patient mix, you are going to have to have a certain percentage of patients who go on to home dialysis or your payment gets cut,” he explained.
That may be well and good for affluent patients on dialysis who have a nice clean home with enough space to be able to do dialysis at home, he noted. But for many rural patients, and especially poor inner city patients with ESKD, “they are lucky if they have a bed to sleep on, never mind a room where they can store peritoneal dialysis solutions,” he said.
“So especially poor patients covered by Medicaid are not going home — there is no way they can go home even if they wanted to. And who gets penalized? The dialysis facility,” he added.
The drive to increase the number of patients who use home dialysis is, of course, driven by projections of how much money can be saved, he said.
But as Wish pointed out, this is not necessarily true because patients who have home dialysis are healthier, can afford their medications, and do not incur the same expenses as in-center patients.
“If you control for health differences between home dialysis patients and dialysis patients in-center, there will be no difference in the expense of providing dialysis, so the whole idea that Medicaid is going to save a ton of money by putting more patients on home dialysis is a fallacy because you haven’t changed the patient,” he underscored.
“And if you make the ‘have not’ facilities less profitable and the more profitable centers can no longer afford to subsidize them, they get closed,” he emphasized.
Erickson reports providing consulting services for Acumen as well as receiving honoraria from Dialysis Clinic Inc, Satellite Healthcare, and the University of Missouri. Wish has reported no relevant financial relationships.
J Am Soc Nephrol. 2021;32:2613-2621. Abstract
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