Variation in dialysis quality measures by facility, neighborhood, and region.

BACKGROUND: We examined whether dialysis facility characteristics, neighborhood demographics, and region are associated with Centers for Medicare and Medicaid Services (CMS) dialysis facility quality measures in order to determine the most important targets for intervention.
METHODS: We linked US census data to the CMS Dialysis Compare File which contains information for facility outcomes for all CMS-certified dialysis facilities in 2007 (n=5616). We then used linear and logistic regression to characterize the association between dialysis facility quality--worse than expected patient survival, and the proportion of individuals in a facility achieving dialysis adequacy (urea reduction rate >65) or target hemoglobin (10<Hgb<12 g/dL)--and dialysis facility characteristics, neighborhood demographics, and region.
RESULTS: Only an increasing proportion of African Americans in the neighborhood is consistently associated with worse dialysis facility outcomes, even after controlling for neighborhood poverty. Facilities with the highest proportion of African Americans in the neighborhood had worse patient survival [odds ratio (OR) 4.6; 95% confidence interval (CI), 2.8-7.6], were less likely to have adequate dialysis (β -1.4; 95% CI, -2.3 to -0.6), and achieve targeted hemoglobin (β -3.1; 95% CI, -4.7 to -1.6) compared to those with the lowest proportion. No other predictor-facility, neighborhood, or region--was consistently associated with dialysis facility quality.
CONCLUSIONS: The proportion of African Americans in the dialysis facility neighborhood is strongly and consistently associated with lower facility quality. Quality improvement efforts are particularly needed for dialysis facilities in minority communities.