Introduction
On-site dialysis in nursing homes (NHs) is an important care model for a medically complex population1. However, prior studies documenting the prevalence and growth of home hemodialysis (HHD) may have inadvertently included NH-based treatments, as current billing mechanisms do not distinguish between institutionally delivered and community-based care. This conflation risks overestimating HHD uptake and obscuring important differences in patient populations and care delivery models2,3. This study separately quantified the growth of NH and community-based home hemodialysis to generate more accurate estimates of HHD growth in the US.
Methods
We conducted a retrospective analysis of Medicare enrollment data and fee-for-service claims linked to Nursing Home Minimum Data Set (MDS) assessments from 2017–2022. The study population included Medicare beneficiaries ≥18 years with end-stage renal disease (ESRD) receiving dialysis with continuous Medicare Parts A and B coverage. We excluded those with acute kidney injury and receiving hospice care. We identified home hemodialysis using revenue center codes (0821) and condition codes (74,76) and NH utilization using MDS assessment dates. We classified home hemodialysis into: (1) Nursing-home hemodialysis (home hemodialysis with concurrent NH utilization in the same month) and (2) community-based home hemodialysis (home hemodialysis without NH utilization). Monthly utilization rates were calculated. We compared demographics and comorbidities between community-based home hemodialysis and nursing-home hemodialysis beneficiaries using chi-squared and Kruskal-Wallis tests as appropriate. All analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC), and statistical significance was set at P < 0.05.
Results
Among 593,162 patient-months (from 91,580 unique individuals) identified as receiving HHD, 94,395 (16%) had evidence of NH utilization in the same month. The proportion of HHD patient-months that were in a NH increased from 13% in 2017 to 21% in 2022. Both modalities grew in absolute terms over the study period, with community-based HHD growing from 2.0% of all dialysis in 2017 to 3.2% in 2022, and nursing-home hemodialysis from 0.3% in 2017 to 0.9% in 2022.
Compared to data from community-based HHD patient-months, data from nursing-home dialysis patient-months included patients who were older (mean +/− standard deviation age 68 +/− 12 vs. 56 +/− 14 years, p < .001), more likely to be female (48 % vs. 38 %, p < .001) and with a higher burden of comorbidities. NH dialysis patient-months included higher rates of congestive heart failure (86% vs. 62%, p < .001), ischemic heart disease (81% vs. 56%, p < .001), and diabetes (88% vs. 64%, p < .001). Dementia was present in 53% of NH patient-months compared to 14% for community-based home hemodialysis (p < .001). Substantial geographic variation was present with the Midwest accounting for 57% of NH hemodialysis patient-months despite representing only 28% of all HHD, while the West had notably lower nursing-home hemodialysis utilization (3% vs. 14% of total home hemodialysis, p < .001).
Discussion
Between 2017 and 2022, both community-based and nursing-home hemodialysis increased. Although the absolute growth was larger in community-based hemodialysis, nursing-home hemodialysis more than doubled, a greater relative increase, resulting in a greater share of total home hemodialysis being delivered in NH settings.
This trend has important implications. Comparative effectiveness studies and quality metrics that treat home hemodialysis as a homogeneous modality may increasingly reflect outcomes of institutionally-supervised nursing-based care rather than home managed dialysis. Recognizing nursing-home hemodialysis as a distinct treatment modality is essential for accurate surveillance, regulatory oversight, reimbursement policy and patient-decision making. Without this distinction, estimates of home hemodialysis use and outcomes risk conflating two very different dialysis delivery circumstances.
The substantial regional differences in nursing-home hemodialysis utilization reflect variations in healthcare infrastructure, provider networks, and local policies. The Midwest’s disproportionate share is attributed to the presence of specialized dialysis providers that have developed expertise and business models focused on NH-based care delivery. In contrast, the lower uptake in the West may relate to state-level regulatory and reimbursement barriers that restrict nursing-home dialysis expansion. Understanding these regional drivers is essential for developing targeted policies that ensure equitable access while maintaining appropriate quality standards across diverse healthcare markets.
Our study has several limitations. The reliance on billing codes and MDS assessments may not capture all nuances of care delivery settings or transitions between modalities during the study period. Additionally, the use of patient-month level exposure may result in misclassification of community-based home hemodialysis with NH utilization as nursing-home hemodialysis. Additionally, our analysis was limited to traditional Medicare beneficiaries and may not be generalizable to those with different insurance coverage.
In conclusion, NH-based dialysis is expanding rapidly and now constitutes a substantial proportion of all home hemodialysis. Distinguishing nursing-home hemodialysis from community-based home hemodialysis is critical to ensure accurate measurement, fair performance comparisons, and evidence-based decision-making by patients, clinicians, and policymakers. Additional work is needed examining hospitalization, mortality, functional status, and return-to-home trajectories separately for NH-based and community-based HHD.
Supplementary Material
Supplemental Digital Content: http://links.lww.com/JSN/F786
Figure 1: Trends in Nursing-Home vs Community-Home Hemodialysis Utilization, 2017–2022.
Note: HHD = Home Hemodialysis. Nursing-Home hemodialysis defined at the patient-month level as months with HHD claims and concurrent Nursing Home utilization based on MDS assessments. Community HHD refers to patient-months with HHD claims and no concurrent Nursing Home utilization.
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