Abstract
The outcomes of patients with incident kidney failure who start hemodialysis are influenced by several factors. Whether hemodialysis facility characteristics are associated with patient outcomes is unclear. We included adults diagnosed as having kidney failure requiring hemodialysis during January 1, 2001 to December 31, 2013 from the Taiwan National Health Insurance Research Database to perform this retrospective cohort study. The exposures included different sizes and levels of hemodialysis facilities. The outcomes were all-cause mortality, cardiovascular death, infection-related death, hospitalization, and kidney transplantation. During 2001–2013, we identified 74,406 patients and divided them in to three groups according to the facilities where they receive hemodialysis: medical center (n = 8263), non-center hospital (n = 40,008), and clinic (n = 26,135). The multivariable Cox model demonstrated that a larger facility size was associated with a low mortality risk (hazard ratio [HR] 0.991, 95% confidence interval [95% CI] 0.984–0.998; every 20 beds per facility). Compared with medical centers, patients in non-center hospitals and clinics had higher mortality risks (HR 1.13, 95% CI 1.09–1.17 and HR 1.11, 95% CI 1.06–1.15, respectively). Patients in medical centers and non-center hospitals had higher risk of hospitalization (subdistribution HR [SHR] 1.11, 95% CI 1.10–1.12 and SHR 1.22, 95% CI 1.21–1.23, respectively). Patients in medical centers had the highest rate of kidney transplantation among the three groups. In patients with incident kidney failure, a larger hemodialysis facility size was associated with lower mortality. Overall, medical center patients had a lower mortality rate and higher transplantation rate, whereas clinic patients had a lower hospitalization risk.
Highlights
The outcomes of patients with incident kidney failure who start hemodialysis are influenced by several factors
A total of 74,406 patients were eligible for analysis, and they were divided into three groups based on the facility level: medical centers, non-center hospitals, and clinics (Fig. 1)
Our study revealed that advanced age, low socioeconomic status, higher comorbidities, vascular types other than fistula at the initial access, non-medical center based facilities and smaller facility size were associated with worse short- and long-term outcomes of adult incident HD patients in Taiwan
Summary
The outcomes of patients with incident kidney failure who start hemodialysis are influenced by several factors. The short- to medium-term outcomes of patients with kidney failure after dialysis initiation may be influenced by many patient factors including their age, sex, comorbidities, and the hemodialysis access types. The associations between facility factors and patient outcomes have been reported in patients requiring procedures or surgeries, such as coronary intervention, cardiac, major abdominal and plastic surgery[10,11]. Because of the advantage of NHI and the low rate of organ donation and transplantation, approximately 90,000 patients with prevalent kidney failure undergo dialysis in Taiwan. Between both dialysis modalities, patients who choose peritoneal dialysis (PD) are usually followed up at the hospital level, whereas hemodialysis (HD) can be performed in both hospitals and clinics. We analyzed patient and facility factors that may have affected the short- and mid-term outcomes of patients with incident kidney failure who initiate HD therapy
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