title: Utilization and outcome of 'out-of-center hemodialysis' in the United States: a contemporary analysis.
abstract: BACKGROUND
  There is increasing interest in the delivery of out-of-center hemodialysis (HD), particularly in the home setting, but little systematic information about its use and outcome in contemporary incident patients is available.
  
  
  METHODS
  Out-of-center HD was defined as HD delivered in a residential setting, mainly at home or in a long-term care facility (such as a nursing home) irrespective of the length and frequency of therapy. All-cause mortality was determined in an observational cohort study of 458,329 adult patients initiating dialysis in the United States with Medicare as a primary payer.
  
  
  RESULTS
  Between 1995 and 2004, out-of-center HD was the initial modality in 1,641 (0.4%) of eligible participants, although there was significant geographic variation. Patients initiating out-of-center HD were younger, more likely to be nonwhite, had fewer comorbidities, a higher median income, and were more likely to be employed than patients initiating in-center HD or peritoneal dialysis (PD). In multivariate analysis, out-of-center HD patients had a higher overall risk of death compared to in-center HD or PD patients (HR = 1.10, 95% CI 1.04, 1.17), although the relative risk of death was lower in younger and healthier patients (HR = 0.78; 95% CI 0.61, 1.00).
  
  
  CONCLUSIONS
  Out-of-center HD is not associated with a survival advantage among unselected patients initiating dialysis in the United States. These results call for better characterization of out-of-center HD in national registries, primarily to effectively compare the use, outcomes and potential benefits of home HD to standard therapies.
authors.affiliation: Division of Nephrology, University of Calgary, Calgary, Alta., Canada. jennifer.macrae@albertahealthservices.ca
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: MacRae
authors.forename: Caren L
authors.initials: CL
authors.lastname: Rose
authors.forename: Bertrand L
authors.initials: BL
authors.lastname: Jaber
authors.forename: John S
authors.initials: JS
authors.lastname: Gill
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006437:Hemodialysis, Home / Q000401:mortality* / Q000706:statistics & numerical data*; D006801:Humans; D007676:Kidney Failure, Chronic; D008134:Long-Term Care; D008297:Male; D008875:Middle Aged; D009735:Nursing Homes / Q000706:statistics & numerical data*; D006435:Renal Dialysis / Q000401:mortality / Q000706:statistics & numerical data; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D055815:Young Adult