Availability and Quality of Dialysis Care in Rural versus Urban US Counties

Am J Nephrol. 2024;55(3):361-368. doi: 10.1159/000537763. Epub 2024 Feb 11.


Introduction: Rural areas face significant disparities in dialysis care compared to urban areas due to limited access to dialysis facilities, longer travel distances, and a shortage of healthcare professionals. The objective of this study was to conduct a national examination of rural-urban differences in quality of dialysis care offered across counties in the USA.

Methods: Data were gathered from Medicare-certified dialysis facilities in 2020 from the Centers for Medicare and Medicaid Services website. To identify high-need counties, county-level estimated crude prevalence of diabetes in adults was obtained from the 2022 CDC PLACES data portal. Our analysis reviewed 3,141 counties in the USA. The primary outcome measured was whether the county had a dialysis facility. Among those counties that had a dialysis facility, additional outcomes were the average star rating, whether peritoneal dialysis was offered, and whether home dialysis was offered.

Results: The type of services offered by dialysis facilities varied significantly, with peritoneal dialysis being the most commonly offered service (50.8%), followed by home hemodialysis (28.5%) and late-shift services (16.0%). These service availabilities are more prevalent in urban facilities than in rural facilities. The Centers for Medicare and Medicaid Services Five Star Quality ratings were quite different between urban and rural facilities, with 40.4% of rural facilities having a ranking of five, compared to 27.1% in urban.

Conclusion: The majority of rural counties lack a single dialysis facility. Counties with high rates of chronic kidney disease, diabetes, and blood pressure, deemed high need, were less likely to have a highly rated dialysis facility. The findings can be used to further inform targeted efforts to increase diabetes educational programming and design appropriate interventions to those residing in rural communities and high-need counties who may need it the most.

Keywords: End-stage kidney disease; Health disparities; Healthcare access; Rural counties.

Publication types

  • Comparative Study

MeSH terms

  • Diabetes Mellitus / epidemiology
  • Diabetes Mellitus / therapy
  • Health Services Accessibility* / standards
  • Health Services Accessibility* / statistics & numerical data
  • Healthcare Disparities / statistics & numerical data
  • Hemodialysis, Home / statistics & numerical data
  • Humans
  • Kidney Failure, Chronic / epidemiology
  • Kidney Failure, Chronic / therapy
  • Medicare / statistics & numerical data
  • Peritoneal Dialysis / standards
  • Peritoneal Dialysis / statistics & numerical data
  • Quality of Health Care* / statistics & numerical data
  • Renal Dialysis* / statistics & numerical data
  • Rural Population / statistics & numerical data
  • United States
  • Urban Population / statistics & numerical data