Re-evaluating the volume-outcome relationship in hemodialysis patients

Health Policy. 2008 Dec;88(2-3):317-25. doi: 10.1016/j.healthpol.2008.03.017. Epub 2008 May 27.


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 (small<or=60, medium 61-120, and large>or=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.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Cohort Studies
  • Female
  • Health Facility Size
  • Humans
  • Kidney Failure, Chronic / therapy
  • Male
  • Middle Aged
  • Outcome Assessment, Health Care*
  • Renal Dialysis*
  • Retrospective Studies
  • Survival Analysis
  • United States