Re-evaluating the volume-outcome relationship in hemodialysis patients.
OBJECTIVES: We sought to determine whether dialysis patient mortality rates are associated with differences in dialysis facility size, and whether this relationship differs among higher risk diabetic and lower-risk non-diabetic patients. METHODS: Using 186,554 adult end-stage renal disease patients initiating hemodialysis at standalone facilities in the United States between 1996 and 1999, we evaluated relationships between dialysis facility size and survival to 5 years. We performed separate analyses for patients with and without diabetes as their primary cause of end-stage renal disease. Facility size was defined according to the number of hemodialysis patients at year's end (smallor=120). RESULTS: Increasing facility size was associated with a reduced risk of mortality at 4 years for both diabetic (HR=0.983 per 10 unit increase, 95% CI=0.967, 0.999) and non-diabetic patients (HR 0.977 per 10 unit increase, 95% CI=0.963, 0.992) dialyzing in small facilities, and for diabetic patients (HR 0.989 per 10 unit increase, 95% CI=0.980, 0.998) dialyzing in medium size facilities. CONCLUSIONS: Smaller facility size is associated with increasing long-term mortality for in-center hemodialysis patients. This relationship appears to be more pronounced among higher-risk diabetic vs. lower-risk non-diabetic patients.
Eisenstein, EL; Sun, JL; Anstrom, KJ; Stafford, JA; Szczech, LA; Muhlbaier, LH; Mark, DB
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