Advance-CTR

Advance RI-CTR Mentored Research Award (2024)

“Optimizing Dialysis Care in Skilled Nursing Facilities: Implementation and Outcomes of On-Site Dialysis"

Kidney failure is a chronic condition in which there is irreversible loss of kidney function requiring either dialysis or kidney transplantation to sustain life. The prevalence of kidney failure in the United States has increased steadily over the past few decades, with over 500,000 Americans requiring dialysis in 2020. Growth in the elderly population, with a 54.6% increase in those ≥75 years and 40.6% in those aged 65-74 years, has been especially significant over the last decade. As the kidney failure population ages, issues around quality of life, palliative care, and care coordination have become increasingly relevant.

A significant subset of dialysis patients receive care in nursing homes, which provide skilled nursing care and rehabilitation services. Traditionally, patients with kidney failure have had limited access to dialysis services within nursing homes, leading to patients having to travel to off-site dialysis centers for treatment. This approach can be challenging for frail, elderly nursing home residents, resulting in reduced quality of life and increased costs due to transportation burdens, as well as delays and schedule conflicts impeding physical therapy. In 2018, CMS issued guidance that addressed care provisions for dialysis patients receiving care in nursing homes specifying dialysis may also be provided within the nursing home itself.  

This represented a significant paradigm shift, and the study's preliminary data demonstrate the use of on-site dialysis in nursing homes has grown significantly after CMS’ new regulation. However, reliable and up-to-date estimates of nursing home utilization amongst the elderly dialysis population and the use of on-site dialysis units are lacking. Without rigorous and comprehensive data on the use of dialysis services among nursing home residents, it will be difficult to design strategies to improve outcomes, reduce costs, and guide shared decision-making for this highly vulnerable population. 

The long-term goal of this study is to optimize outcomes for older patients with end-stage kidney disease by reducing disparities and improving access to and quality of care. The objective of this study, which is the next step in this long-term goal, is to determine the clinical and sociodemographic characteristics of nursing home patients with kidney failure and characterize the use of onsite dialysis for this population. Using national data from the United States Renal Data System (USRDS), the study will analyze demographics, comorbidities, dialysis modality, transitions between care settings, and health outcomes. This study addresses a critical knowledge gap at the intersection of two complex, high-cost sectors of healthcare. 

This study has two aims:

• Identify disparities in the provision of on-site dialysis services among SNF residents based on demographic and geographic factors. Utilize national registry data to determine whether race, ethnicity, income, or geographical location influence access to on-site dialysis. The study hypothesizes that patients dialyzing in on-site units will have higher socioeconomic status and be less likely to be black or Hispanic.
• Compare clinical outcomes, specifically mortality rates and hospitalization rates, of SNF residents receiving dialysis on-site to those receiving dialysis at a traditional dialysis unit. The study hypothesizes that patients dialyzing in on-site units will have lower rates of hospitalization.

This project has the potential for high impact given the critical knowledge gaps it addresses regarding an extremely high-risk, high-cost population at the intersection of two complex sectors of healthcare. Further, the findings can inform rapidly evolving federal policy-making regarding the provision of dialysis in nursing homes and provide evidence about care and health outcomes for patients with kidney failure in nursing homes. At an institutional level, this project would expand research in health services and epidemiology and provide pilot data to leverage larger awards. More broadly, funding would build research capacity in Rhode Island by supporting an early-stage investigator dedicated to advancing patient-centered care and reducing disparities for state residents with chronic illness.

This proposal aligns with at least 3 federal priorities: i) Increasing the provision of home dialysis, ii) improving quality of care in nursing homes, and iii) addressing disparities in access to care. Through the proposed work, experience will be gained in training and mentoring in health services research, econometrics, and causal inference while this study will enhance the understanding of both the demographics and outcomes of an understudied population. This proposal will lead to the submission of a K23 career development award to further characterize this understudied, highly burdened population and to develop strategies to both inform shared decision making with dialysis patients residing in skilled nursing facilities and to optimize the care of dialysis patients in skilled nursing facilities.