Geographic and temporal trends in peritoneal dialysis services in the United States between 1995 and 2003.

backgroundPeritoneal dialysis (PD) is the preferred dialysis modality for many patients with end-stage renal disease (ESRD) in the United States. However, in sharp contrast to the high rates of PD use in other industrialized countries, PD use in the United States is low and decreasing. PD availability is a necessary condition for PD use; however, little is known about the availability and geographic distribution of PD services. This study describes trends in the regional supply of PD services in dialysis facilities between 1995 and 2003. STUDY

designLongitudinal cohort study. SETTING &

participantsNonfederal outpatient dialysis facilities treating patients with ESRD in the United States using data from the US Renal Data System. PREDICTORS: Annual ESRD patient and dialysis facility composition in hospital referral regions. OUTCOME: Annual proportion of dialysis facilities offering PD treatment services in hospital referral regions.

resultsThe average proportion of facilities offering PD services in hospital referral regions was 56% in 1996, which decreased to 47% in 2003. There was geographic variation in PD services, with greater PD availability in metropolitan cities (compared with rural regions) and the Northeast (relative to the South and Midwest). Variation in PD availability was not explained by disease trends or patient characteristics believed to be important for PD use. An increasing regional presence of chain-affiliated facilities was associated with less PD supply. LIMITATIONS: Accuracy of patient registry data, inability to account for consolidation of PD services among chain providers, sensitivity of results to definition of regional markets.

conclusionsThe small and decreasing availability of PD therapy seems counterintuitive given its demonstrated appeal to patients and payers. Further research is needed to investigate dialysis facilities' role in the underuse of a potentially useful therapy.