title: Geography matters: relationships among urban residential segregation, dialysis facilities, and patient outcomes.
abstract: BACKGROUND
  End-stage renal disease disproportionately affects black Americans. However, the impact of residential segregation by race-a prominent feature of many U.S. cities--on outcomes of patients receiving dialysis and on facility performance has not been evaluated.
  
  
  OBJECTIVE
  To examine the relationship among racial composition of ZIP codes in metropolitan areas, outcomes of patients receiving dialysis, and characteristics of dialysis facilities.
  
  
  METHODS
  Retrospective cohort study of patients receiving dialysis and cross-sectional study of dialysis facilities.
  
  
  METHODS
  U.S. metropolitan ZIP codes with differing percentages of black residents.
  
  
  METHODS
  Black and non-Hispanic white patients who initiated long-term dialysis between 1 January 1995 and 31 December 2002 (n = 399,424) and dialysis facilities in operation in December 2004 (n = 3244).
  
  
  METHODS
  Mortality and time to transplantation among patients receiving dialysis, and performance of dialysis facilities on the basis of quality indicators (anemia management, dialysis adequacy, and facility-level mortality rates).
  
  
  RESULTS
  Most black patients (50.3%) but few white patients (5%) lived in the 3% (n = 769) of ZIP codes in which most residents were black. In analyses adjusted for patient and ZIP code characteristics, mortality rates were higher among white patients but not among black patients living in areas with a higher percentage of black residents (adjusted hazard ratio for ZIP codes with > or =75% black residents vs. <10% black residents, 1.14 [95% CI, 1.07 to 1.21] for white patients and 1.02 [CI, 0.99 to 1.06] for black patients). Time to transplantation was longer among both black and white patients (adjusted hazard ratio for ZIP codes with > or =75% black residents vs. <10% black residents, 0.84 [CI, 0.78 to 0.92] and 0.63 [CI, 0.57 to 0.71] for black patients and white patients, respectively). Dialysis facilities located in areas with a higher percentage of black residents were more likely to have higher-than-expected mortality rates and were less likely to meet performance targets.
  
  
  CONCLUSIONS
  Patient-level analyses were restricted to black and non-Hispanic white patients. Patient-level and facility-level analyses focused only on the percentage of black residents in each ZIP code.
  
  
  CONCLUSIONS
  The racial composition of urban residential areas is associated with time to transplantation and dialysis facility performance on standard quality measures. Closer scrutiny of care provided to patients receiving dialysis who live in predominantly black residential areas and to dialysis facilities operating in these areas may be warranted.
authors.affiliation: San Francisco General Hospital, University of California, San Francisco, Veterans Affairs Medical Center, San Francisco, California 94110, USA. rrodriguez@medsfgh.ucsf.edu
authors.forename: Rudolph A
authors.initials: RA
authors.lastname: Rodriguez
authors.forename: Saunak
authors.initials: S
authors.lastname: Sen
authors.forename: Kala
authors.initials: K
authors.lastname: Mehta
authors.forename: Sandra
authors.initials: S
authors.lastname: Moody-Ayers
authors.forename: Peter
authors.initials: P
authors.lastname: Bacchetti
authors.forename: Ann M
authors.initials: AM
authors.lastname: O'Hare
mesh_terms: D001741:Black or African American / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D005260:Female; D006268:Health Facilities / Q000706:statistics & numerical data*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000208:ethnology* / Q000401:mortality / Q000628:therapy*; D016030:Kidney Transplantation; D015993:Life Tables; D008297:Male; D011204:Poverty Areas; D016016:Proportional Hazards Models; D006435:Renal Dialysis; D012111:Residence Characteristics; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D013997:Time Factors; D014481:United States / Q000453:epidemiology; D014505:Urban Population