Infection Control Measures in Dialysis Facilities after COVID-19: Disparities in Adoption and Impact on Hospitalization and Mortality

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PROJECT SUMMARY The COVID-19 pandemic threatens the health of patients with kidney failure because end-stage kidney disease (ESKD) is a risk factor for COVID-19 related death. Most patients with kidney failure undergo hemodialysis treatment in an outpatient dialysis facility three times a week alongside other patients. This can result in unavoidable patient clustering and an increased risk of viral transmission. Further, patients with kidney failure often have multiple comorbidities, high baseline rates of mortality, and are more likely to be black or Hispanic, racial/ethnic minority groups that have been disproportionately impacted by the pandemic. High hospitalization rates for ESKD patients also demands a health care system that allows seamless care coordination between the outpatient dialysis facilities and hospitals. In order to mitigate patients' risk of contracting COVID-19, facilities could implement several precautionary measures, including reducing the duration of each hemodialysis treatment session, assigning patients to separate facilities or shifts that specifically accommodate COVID-19 patients, establishing additional “isolation” stations within a facility, offering training and support for patients receiving home dialysis, and providing care to nursing home residents in the nursing home as opposed to an outpatient dialysis facility. Some dialysis facilities have reported implementing these strategies, but systematic national data about their adoption and association with meaningful patient outcomes are not known. Using data from the universe of all outpatient dialysis facilities and a census of patients with kidney failure undergoing dialysis for the period 2018-2022, this project has three aims. First, we estimate the extent to which COVID-19 spurred the facility-level adoption of infection-control practices, and to examine the heterogeneity in adoption across facilities. Our working hypothesis is that facilities affiliated with LDOs, those located in disadvantaged neighborhoods, and those in counties with high infection rates will be more likely to adopt protective measures in response to the threat of COVID-19. Second, we investigate the effectiveness of facility-level infection-control responses on COVID-19 related- and all-cause hospitalization and mortality. Our working hypothesis is that infection control measures resulted in a reduction of infection- related hospitalizations and mortality, but non-COVID-19 and overall hospitalization and mortality rates increased. Third, we estimate the extent to which hemodialysis sessions were impacted for dialysis patients admitted to hospitals in high-COVID-19 counties. Our working hypothesis is that dialysis patients admitted to hospitals in counties with high COVID-19 infection rates or COVID-19 “hotspots” experience greater reductions in dialysis sessions. Overall, our study will have a positive impact since dissemination of information about responses found effective will allow other facilities to adopt them, and reduce COVID-19 transmission in this vulnerable patient population.