Location, location, location? A study of peritoneal dialysis services in the United States

Dialysis treatment of end-stage renal disease (ESRD) has become an important health policy concern because of growth in the number of patients with kidney failure and the financial burden on patients and payers. The development of peritoneal dialysis (PD) offered a clinically effective, more convenient and less expensive alternative to hemodialysis, the dominant form of renal therapy treatment for ESRD in the US. Despite studies that demonstrated the appeal of PD among patients, providers, and payers, and Medicare program payment policies that promoted its use, utilization of PD has been limited. Prior studies have examined patient and physician factors of PD utilization and confirmed a significant preference for PD that is not reflected in practice. Less attention has been paid to the role of treatment facilities. This study uses location theory to elucidate the mechanisms behind the availability and distribution of PD services over time.

This longitudinal study uses national data on ESRD patients and outpatient dialysis facilities from the US Renal Data System and the Centers for Medicare and Medicaid Services. Spatial and longitudinal regression methods, previously underused tools in the study of ESRD, are used to examine conditions associated with PD service offerings among dialysis facilities between 1995 and 2003.

Throughout the study period, fewer than half of facilities offered PD. GIS mappings demonstrate the availability of PD to vary temporally and geographically. Results from multivariate regression models indicate that market conditions influence facilities' decision to offer PD services, but in unexpected ways. Most market conditions considered favorable for generating revenue and profit from a PD service line were, in fact, negatively associated with facilities' likelihood of offering PD.

The locational distribution of PD appears to reflect the effect of PD as a scarcely utilized service, suggesting that there may be more behind the locational distribution of PD than profit-seeking among dialysis facilities. Results from this study contribute to the scant literature on PD services and lay the foundation for further research and better understanding of the organization of this potentially useful therapy for ESRD.