Statement of the Problem: End stage renal disease (ESRD), a potential consequence of diabetes, hypertension and other chronic conditions, leaves the individual in need of a kidney transplant or kidney dialysis. The disease disproportionately affects poor and minority individuals; an estimated 22% of ESRD patients live in rural America. Because ESRD automatically qualifies an individual for Medicare, the Medicare payment structure can markedly affect whether dialysis providers enter or leave a particular area. Medicare rule changes addressing "composite rate" billing and volume of services are currently being developed and may affect rural service availability. The current distribution of dialysis facilities across levels of rurality, and the characteristics of these facilities, has not been studied.

Project Goals: The project will address three questions:

• What is the current distribution of dialysis facilities, by characteristics and capacity, across levels of rurality?
• How do dialysis facility performance measures compare across levels of rurality?
• How does the distribution of facilities compare to estimated need?

Method: Using files from Medicare's Dialysis Compare and the Standard Analysis File of the US Renal Data System, the project will describe the current distribution of dialysis facilities at the ZIP Code and county levels. Facility distribution will be compared to population distribution. Population per station calculations will be used to evaluate the current distribution of services at the county level across levels of rurality. The quality of current services, as measured by patient outcomes, will also be assessed.

Anticipated Publications and Products. Technical reports with detailed maps of facility availability will be developed. Manuscripts will be submitted to appropriate journals in the fields of nephrology and health services research. Key Fact Sheets and Policy Briefs will be made available for policymakers and relevant advocate organizations and programs.

Publications

• Dialysis Availability in Rural America
  Rural and Minority Health Research Center
  Date: 01/2013
  This study explores the availability of dialysis services in rural America, including the prevalence of dialysis use across urban and rural counties, travel distance for services, and dialysis quality outcomes.
• Geographic Disparities in Mortality Among the End Stage Renal Disease Patients: An Analysis of the United States Renal Data System, 2007-08.
  Journal Article
  Rural and Minority Health Research Center
  Date: 06/2016
  Explores the association between morality, rurality, and distance from the treatment facility of patients with end-stage renal disease (ESRD). Rural patients were found to have a mortality advantage.