Trends in Dialysis Facility Access in the United States from 2018-2023 and Association with Area Socioeconomic Disadvantage

Background: After several years of stable growth, recent data indicate that the dialysis market in the US may be contracting. We sought to examine trends in US dialysis facility growth and closures, and evaluate whether closures were disproportionately affecting socio-economically disadvantaged populations. Methods: We conducted a serial cross-sectional study of dialysis facilities from 2018 until 2023 using the Provider of Services data from Centers for Medicare & Medicaid Services. We performed geospatial analysis of facility openings and closures across the U.S. and examined differential trends in dialysis facility access over time. We evaluated differences in CDC/ATSDR social vulnerability index (SVI), census region, rural or urban area designation, and racial and ethnic composition between census tracts (CT) in which the total number of dialysis facilities decreased, increased or remained unchanged between 2018 and 2023. Results: We identified 8220 unique dialysis facilities across 7120 CTs between 2018 and 2023. During this time– as the number of individuals with prevalent end-stage renal disease rose from 782,844 in 2018 to 815,142 by the end of 2023– the annual number of facility closures increased consistently, whereas the number of newly opened facilities decreased (Fig 1). Facility closures and openings tended to occur in distinct CTs. Overall, access to dialysis services decreased in 563 (7.9%) neighborhoods. CTs in rural areas and in the Midwest were more likely to experience dialysis facility closures compared with urban CTs (10.5% of rural CTs vs. 8.4% of urban CTs with closures, p=0.01, and 10.3% of Midwest CTs vs. 6.2% of West CTs with closures, p <0.01). Neighborhoods with higher SVI did not experience more closures (p=0.61). Conclusion: Trends in dialysis facility closure raise concerns about loss of access to dialysis services nationwide, with rural communities most urgently affected. Funding: Other NIH Support - 1R21MD01939401