Introduction
On-site dialysis in nursing homes is an important care model for a medically complex population.1 However, previous studies documenting the prevalence and growth of home hemodialysis (HD) may have inadvertently included nursing home–based treatments, as current billing mechanisms do not distinguish between institutionally delivered and community-based care. This conflation risks overestimating home HD uptake and obscuring important differences in patient populations and care delivery models.2–6 This study separately quantified the growth of nursing home– and community-based home HD to generate more accurate estimates of home HD growth in the United States
Methods
We conducted an analysis of Medicare enrollment data and fee-for-service claims linked to nursing home minimum data set (MDS) assessments from 2017 to 2022. The study population included Medicare beneficiaries ≥18 years with ESRD receiving dialysis with continuous Medicare Parts A and B coverage. We excluded those with AKI and receiving hospice care. We identified home HD using revenue center codes (0821) and condition codes (74 and 76) and nursing home utilization using MDS assessment dates. We classified home HD into (1) nursing home hemodialysis (home HD with concurrent nursing home utilization in the same month) and (2) community-based home HD (home HD without nursing home utilization). Monthly utilization rates were calculated. We compared demographics and comorbidities between community-based home HD and nursing home hemodialysis beneficiaries using the 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. Additional details are available in Supplemental Methods.
Results
Among 593,162 patient-months (from 91,580 unique individuals) identified as receiving home HD, 94,395 (16%) had evidence of nursing home utilization in the same month. The proportion of home HD patient-months that were in a nursing home increased from 13% in 2017 to 21% in 2022. Both modalities grew in absolute terms over the study period, with community-based home HD 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 (Figure 1).
Figure 1.
Trends in nursing home versus community home HD utilization, 2017–2022. Nursing home hemodialysis defined at the patient-month level as months with home HD claims and concurrent nursing home utilization on the basis of MDS assessments. Community home HD refers to patient-months with home HD claims and no concurrent nursing home utilization. HHD, home hemodialysis; MDS, minimum data set.
Compared with data from community-based home HD patient-months, data from nursing home dialysis patient-months included patients who were older (mean±SD age 68±12 versus 56±14 years, P < 0.001), more likely to be female (48% versus 38%, P < 0.001), and with a higher burden of comorbidities. Nursing home dialysis patient-months included higher rates of congestive heart failure (86% versus 62%, P < 0.001), ischemic heart disease (81% versus 56%, P < 0.001), and diabetes (88% versus 64%, P < 0.001). Dementia was present in 53% of nursing home patient-months compared with 14% for community-based home HD (P < 0.001). Substantial geographic variation was present, with the Midwest accounting for 57% of nursing home hemodialysis patient-months despite representing only 28% of all home HD, whereas the West had notably lower nursing home hemodialysis utilization (3% versus 14% of total home HD, P < 0.001).
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 HD being delivered in nursing home settings.
This trend has important implications. Comparative effectiveness studies and quality metrics that treat home HD as a homogeneous modality may increasingly reflect outcomes of institutionally supervised nursing-based care rather than home-managed dialysis.7 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 HD use and outcome risk conflating two very different dialysis delivery circumstances.
The substantial regional differences in nursing home hemodialysis utilization reflect variations in health care infrastructure, dialysis and nursing home organization networks, and local policies. The Midwest's disproportionate share is attributed to the presence of specialized organizations that have developed expertise and business models focused on nursing home–based care delivery. By 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 health care 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. In addition, the use of patient-month level exposure may result in misclassification of community-based home HD with nursing home utilization as nursing home hemodialysis. In addition, our analysis was limited to traditional Medicare beneficiaries and may not be generalizable to those with different insurance coverage.
In conclusion, nursing home–based dialysis is expanding rapidly and now constitutes a substantial proportion of all home HD. Distinguishing nursing home hemodialysis from community-based home HD 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 nursing home–based and community-based home HD.
Acknowledgments
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US Government.
Disclosures
Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/JSN/F785.
Author Contributions
Conceptualization: Ankur D. Shah, Amal N. Trivedi.
Data curation: Yoojin Lee, Yanru Liao, Ankur D. Shah.
Formal analysis: Yoojin Lee, Yanru Liao, Ankur D. Shah.
Funding acquisition: Ankur D. Shah, Amal N. Trivedi.
Investigation: Ankur D. Shah, Amal N. Trivedi.
Methodology: Yoojin Lee, Yanru Liao, Ankur D. Shah, Amal N. Trivedi.
Project administration: Amal N. Trivedi.
Resources: Vincent Mor, Christopher H. Schmid, Amal N. Trivedi.
Software: Ankur D. Shah, Amal N. Trivedi.
Supervision: Vincent Mor, Christopher H. Schmid, Amal N. Trivedi.
Writing – original draft: Ankur D. Shah.
Writing – review & editing: Vincent Mor, Christopher H. Schmid, Amal N. Trivedi.
Funding
The project described was supported by Institutional Development Award Number U54GM115677 from the National Institute of General Medical Sciences of the National Institutes of Health, which funds Advance Clinical and Translational Research (Advance-CTR), by the Center for Gerontology & Healthcare Research Clinician Science Award, and by the National Institute on Minority Health and Health Disparities under award number R01MD017080 and the National Institute of Diabetes and Digestive and Kidney Diseases under award number R01DK129388.
Declarative Statements
This study is exempt from the Institutional Review Board or Ethics Committee approval, and we have provided the reason for exemption. Exemption 4: secondary research using identifiable information or biospecimens if publicly available, or recorded such that participants cannot be reidentified. This study was approved by the Brown University Institutional Review Board.
Data Availability Statements
Data belong to a third party, and authors are not authorized to share the data. Identity of Third Party: Research Data Assistance Center. Reason for Restriction: Data are available only through Research Data Assistance Center directly.
Supplemental Material
This article contains supplemental material online, published as provided by the authors, at http://links.lww.com/JSN/F786.
References
- 1.Bellin EY Hellebrand AM Kaplan SM, et al. Epidemiology of nursing home dialysis patients-A hidden population. Hemodial Int. 2021;25(4):548–559. doi: 10.1111/hdi.12943 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Nadeau-Fredette AC, Shen JI, Perl J. Comparing cardiovascular events across home dialysis modalities: adjusting the unadjustable? Kidney360. 2024;5(4):489–491. doi: 10.34067/KID.0000000000000397 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Wallach JD, Medaura JA, Stern L. Home dialysis: there's no place like home. Curr Opin Nephrol Hypertens. 2025;34(2):131–137. doi: 10.1097/MNH.0000000000001056 [DOI] [PubMed] [Google Scholar]
- 4.Bellin EY Hellebrand AM Kaplan SM, et al. Post-dialysis recovery time in ESRD patients receiving more frequent hemodialysis in skilled nursing facilities. Hemodial Int. 2022;26(3):424–434. doi: 10.1111/hdi.13012 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Bellin EY Hellebrand AM Markis WT, et al. More frequent On-Site dialysis may hasten return to home for nursing home patients with end-stage kidney disease. Kidney360. 2024;5(8):1126–1136. doi: 10.34067/KID.0000000000000487 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Bellin EY Markis WT Hellebrand AM, et al. Improved nursing home end-stage renal disease patient participation in physical therapy with onsite, more frequent dialysis. Hemodial Int. 2023;27(4):465–474. doi: 10.1111/hdi.13112 [DOI] [PubMed] [Google Scholar]
- 7.Bieber SD, Young BA. Home hemodialysis: core curriculum 2021. Am J Kidney Dis. 2021;78(6):876–885. doi: 10.1053/j.ajkd.2021.01.025 [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data belong to a third party, and authors are not authorized to share the data. Identity of Third Party: Research Data Assistance Center. Reason for Restriction: Data are available only through Research Data Assistance Center directly.