Study Suggests Racial Disparities in Access to High-Quality Dialysis Facilities

Eugene Lin, MD, MS

Credit: USC Schaeffer Institute

New research is providing clinicians with an overview of how care continuity with a predialysis nephrologist impacts end-stage kidney disease (ESKD) patients’ dialysis start quality, additionally highlighting racial disparities in dialysis care.1

Study findings suggest most patients with ESKD are likely to initiate dialysis at their predialysis nephrologists’ primary facility, even if it has a poor rating through the Centers for Medicare and Medicaid Services Dialysis Facility Compare (DFC) Star Program. Of note, Black patients more frequently saw nephrologists with low-quality primary facilities and in turn received lower quality dialysis care.1

According to the American Kidney Fund, an estimated 35.5 million people in the US have kidney disease, 815,000 of whom are living with kidney failure. While transplantation is widely considered the optimal treatment for ESKD, the shortage of available donor kidneys means the majority of people who develop kidney failure are treated with dialysis.2

“Research is sparse on how patients choose dialysis facilities and whether patients prioritize care continuity with the nephrologist, travel distance, or facility quality. Although the first 2 are transparent to patients, the third is opaque,” Eugene Lin, MD, MS, a nephrologist and assistant professor of medicine in the division of nephrology and hypertension at the University of Southern California, and colleagues wrote.1 “Care continuity in dialysis is not well studied, especially during the transition to dialysis. Patients may be negatively impacted by care continuity if their nephrologists primarily manage patients at low-quality facilities.”

To address this gap in research, investigators examined Medicare administrative data for adult patients initiating dialysis for ESKD between January 2015 and October 2020. Data from the US Renal Data System were linked to annual facility quality ratings from DFC, physician specialty from the National Plan and Provider Enumeration System, and zip code-level sociodemographic information from Census data and the American Community Survey.1

The study’s primary outcomes were starting dialysis at the nephrologist’s primary facility, whether the starting facility was high quality based on DFC 4 or 5 star ratings, mortality and hospitalization rates, and racial and ethnic disparities in high-quality primary facilities and in starting dialysis at high-quality facilities.1

In total, investigators identified 143,776 eligible adult patients. Among the cohort, the median age was 73 (interquartile range, 67-79) years, 55% of patients were male, and 67% of patients were non-Hispanic White. Investigators noted 31% of patients had predialysis nephrologists with nearby primary facilities and 45% had managing nephrologists with high-quality primary facilities.1

Upon analysis, primary facility starts were lower as the primary facility’s quality increased (0.5 percentage points lower for every 1-star increase in rating; 95% CI, 0.1-0.8; P = .03). In contrast, primary facility starts were 33.9 percentage points (95% CI, 33.0- 34.9; P <.001) more likely when primary facilities were close to patients than when distant.1

Investigators noted patients were 20.2 percentage points (95% CI, 19.2-21.2; P <.001) more likely to start dialysis in nearby facilities when the primary facility was close versus distant and 7.4 percentage points (95% CI, 6.9-7.9; P <.001) more likely to have a high-quality start for each additional star in rating.1

In unadjusted analysis, patients whose nephrologists’ primary facilities were high quality had lower mortality and hospitalization rates than patients whose nephrologists’ primary facilities were low quality. However, after adjusting for confounders, mortality differences were not significant by primary facility quality, but differences in hospitalization persisted.1

Specifically, for each additional star in primary facility rating, patients had a 4.5 per 100 person-year lower hospitalization rate (95% CI, 2.8-6.1; P <.001), or a 17.4 per 100 person-year decrease in hospitalization rates (95% CI, 11.1-23.5) when the primary facility had 5 stars versus 1 star.1

Additionally investigators pointed out Black patients were 2.8 percentage points (95% CI, 1.7-3.9) less likely to start at 4-star or 5-star facilities and 2.0 percentage points (95% CI, 1.0-3.0) less likely to be treated by nephrologists with 4-star or 5-star primary facilities compared with White patients.1

“Primary facility starts were common, especially if primary facilities were close to patients and even when they were low quality,” investigators concluded.1 “Given that starts did not correlate with 5-star ratings, policymakers may wish to bolster the DFC’s effectiveness, including improved publicity to patients. Primary facility starts may exacerbate racial disparities in dialysis quality because nephrologists with high-quality facilities were less accessible to Black patients.”

References

1. Lin E, Lung KI, Rapista D, et al. Care Continuity, Nephrologists’ Dialysis Facility Preferences, and Outcomes. JAMA Health Forum. 2025;6(4):e250423. doi:10.1001/jamahealthforum.2025.0423

2. American Kidney Fund. Quick kidney disease facts and stats. February 11, 2025. Accessed April 14, 2025. https://www.kidneyfund.org/all-about-kidneys/quick-kidney-disease-facts-and-stats