Utilization and outcome of 'out-of-center hemodialysis' in the United States: a contemporary analysis

Abstract

Background: There is increasing interest in the delivery of out-of-center hemodialysis (HD), particularly in the home setting, but little systematic information about its use and outcome in contemporary incident patients is available.

Patients and methods: Out-of-center HD was defined as HD delivered in a residential setting, mainly at home or in a long-term care facility (such as a nursing home) irrespective of the length and frequency of therapy. All-cause mortality was determined in an observational cohort study of 458,329 adult patients initiating dialysis in the United States with Medicare as a primary payer.

Results: Between 1995 and 2004, out-of-center HD was the initial modality in 1,641 (0.4%) of eligible participants, although there was significant geographic variation. Patients initiating out-of-center HD were younger, more likely to be nonwhite, had fewer comorbidities, a higher median income, and were more likely to be employed than patients initiating in-center HD or peritoneal dialysis (PD). In multivariate analysis, out-of-center HD patients had a higher overall risk of death compared to in-center HD or PD patients (HR = 1.10, 95% CI 1.04, 1.17), although the relative risk of death was lower in younger and healthier patients (HR = 0.78; 95% CI 0.61, 1.00).

Conclusion: Out-of-center HD is not associated with a survival advantage among unselected patients initiating dialysis in the United States. These results call for better characterization of out-of-center HD in national registries, primarily to effectively compare the use, outcomes and potential benefits of home HD to standard therapies.

Fig. 1.

Map of out-of-center HD rate (per 1,000 incident patients with ESRD initiating dialysis) in the US between 1995 and 2004 stratified by USRDS network.

Fig. 2.

Cumulative probability of patient survival stratified by initial dialysis modality.