Racial, socioeconomic, and rural-urban disparities persist in dialysis care, according to new data presented at the American Society of Nephrology’s Kidney Week 2021.

Marc Turenne, PhD, Health Policy and Practice Program Scientific Director for Arbor Research Collaborative for Health in Ann Arbor, Michigan and colleagues performed analyses of Medicare claims and CROWNWeb data for 2019 and found that disparities in 13 of the 16 quality indicators related to race or income.

Race Differences

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Arteriovenous fistula use was lower among Black than White patients (57.6 vs 67.0%). Outpatient emergency department visits were significantly higher among Black patients compared with White patients (17.0 vs 14.9 per 100 patient-months). Anemia (hemoglobin less than 10 g/dL) affected more Black than White patients (26.5% vs 23.6%).

Hospice use at death was highest for White patients (31.6%) and significantly lower for Black (20.2%), American Indian/Alaskan Native (19.6%), Asian (19.0%), and Pacific Islander (17.0%) patients.

Income Disparities

The investigators examined differences between patients with dual eligibility for Medicare based on age (older than 65 years) and Medicaid due to low income and those without dual eligibility. Dual eligible patients were significantly more likely to dialyze with a catheter long term (11.6% vs 10.0%) and to experience a dialysis access-related hospitalization (0.8 vs 0.6 per 100 patient-months) than similar patients without that status.

Dual eligible patients were more likely to be hospitalized overall (16.1 vs 12.9 per 100 patient-months), be readmitted within 30 days (30.6% vs 25.5%), and have an outpatient emergency department visit (18.6 vs 12.0 per 100 patient-months). They were also more likely to use opioids long term (11.1% vs 5.9%).

Rural vs Urban Differences

Outpatient emergency visits were significantly higher among patients residing in rural vs urban areas (20.9 vs 14.7 per 100 patient-months). Rural residents were significantly more likely to use opioids long term (11.6% vs 8.7%). They were also more likely to die prematurely (1.7 vs 1.4 per 100 patient-months).

“Nationally, there are ongoing racial, socioeconomic, and rural-urban disparities among dialysis patients in a range of quality indicators,” Dr Turenne told Renal & Urology News. In addition, variation in the number of disparities observed across ESRD Networks suggests opportunities for achieving both improved and more equitable outcomes in specific geographic areas.

“Broad awareness of these disparities is needed among health care providers, the ESRD Networks, policymakers, and payers. All may have important roles in eliminating gaps in quality of care.”

Health care providers can focus on optimal selection and management of vascular access for each patient, he said. They can also make a targeted effort to prevent avoidable hospitalizations among economically disadvantaged patients.

Dr Turenne cited recent efforts by The Centers for Medicare & Medicaid Services (CMS) to promote health equity across its programs. As part of the 2021 ESRD QIP Proposed rule, CMS sought input from the renal community and outlined approaches for measuring dialysis facility performance with respect to dialysis populations with social risk factors.

On October 29, 2021, CMS adopted changes to the ESRD Treatment Choices (ETC) Model to reduce disparities in the use of renal replacement therapies. Starting in January 2022, the ETC Model strengthens incentives for both participating dialysis facilities and managing clinicians to increase rates of home dialysis and kidney transplantation among beneficiaries of lower socioeconomic status.


Turenne M, Cogan CM, Pearson J, Huff ED. Disparities in quality of care for dialysis patients. Presented at: Kidney Week 2021; November 2-7, 2021. Poster: PO0791.