Uneven geographic distribution of dialysis facility expansion and its differential impact on health outcomes among patients with end-stage kidney disease - dialysis is one of the most frequently…

The National Institute for Minority Health and Health Disparities awarded the National Bureau of Economic Research Inc. $2,159,469 on September 3, 2026, under the Minority Health and Health Disparities Research program (CFDA 93.307) to conduct a Project Grant investigating the geographic distribution of dialysis facility expansion and its effects on health outcomes among patients with end-stage kidney disease.

The research will analyze whether the 70 percent increase in dialysis centers over the past 20 years and accompanying improvements in technology and care protocols have benefited all communities equally or have widened disparities. Using 10 years of national Medicare claims linked with facility- and community-level data, the study will test three primary hypotheses: that recent facility growth has unevenly increased dialysis capacity across communities defined by socioeconomic status and rurality; produced uneven benefits whereby patients in higher-resourced areas experience greater improvements in access to high-quality facilities and health outcomes; and widened differences within communities, as facility openings may benefit some patients more than others despite shared zip codes. The work focuses particularly on disparities affecting Black, Hispanic, Medicaid-eligible, and rural populations.

Performance of work is located in Cambridge, Massachusetts. The award period extends from September 3, 2026, through July 31, 2030.

Uneven geographic distribution of dialysis facility expansion and its differential impact on health outcomes among patients with end-stage kidney disease - dialysis is one of the most frequently used outpatient services in medicine. Because treatment generally involves multiple weekly sessions, the proximity of dialysis facilities to the patients who rely on them is critically important. The total number of dialysis centers has increased by 70% over the last 20 years. In addition, there have been recent improvements in dialysis technology and care protocols that can significantly improve clinical outcomes, though not all facilities offer these services. However, IT is unknown whether the benefits of dialysis center market expansion and/or technological advancements have been evenly distributed across all communities. Indeed, major differences persist in where and how dialysis is delivered, particularly for black, hispanic, medicaid-eligible, and rural populations. Our long-term goal is to identify mechanisms through which changes in dialysis infrastructure influence disparities in eskd treatment and outcomes. Towards this end, the overall objective of this project is to determine how the benefits of dialysis market expansion are experienced across and within communities. Using dialysis facility expansion as an identification strategy and 10 years of national medicare claims linked with facility- and community-level data, this study will test the hypothesis that recent growth in outpatient dialysis facilities has: (aim 1) unevenly increased dialysis capacity across communities defined by socioeconomic status and rurality; (aim 2) produced uneven benefits across communities, whereby patients in higher-resourced areas experience greater improvements in access to high-quality facilities and health outcomes; and (aim 3) widened differences within communities, as facility openings may benefit some patients more than others even when living in the same ZIP code. Our longitudinal, population-based approach is innovative because IT will capture how changes in dialysis infrastructure influence access and outcomes over time, will include both traditional medicare and medicare advantage beneficiaries, and will evaluate access based on real-world, care-seeking behavior rather than static facility catchment areas. This research will generate a first-of-its-kind, nationally representative, longitudinal database of dialysis facility openings and closures, quality shifts, and eskd patient clinical outcomes. By linking these data to demographic and geographic community characteristics, we offer a novel framework for identifying actionable disparities in eskd care. These findings will identify specific communities in which additional interventions (e.g., subsidized transport to high-quality facilities, regulatory incentives to encourage facility openings in high-ADI areas) could yield the greatest benefits for all patients, thus advancing niddk's mission.