Patient Care Staffing Levels and Facility Characteristics in US Hemodialysis Facilities

Background Higher numbers of registered nurses (RNs) per patient have been associated with improved patient outcomes in acute-care facilities. Variation in and associations of patient care staffing levels and hemodialysis facility characteristics have not been examined previously. Study Design Cross-sectional study using Poisson regression to examine associations between patient care staffing levels and hemodialysis facility characteristics. Setting & Participants 4,800 US hemodialysis facilities in the 2009 Centers for Medicare & Medicaid (CMS) End-Stage Renal Disease Annual Facility Survey (CMS-2744 form). Predictors Facility characteristics, including profit status, freestanding status, chain affiliation, and geographic region, adjusted for facility size, capacity, functional type, and urbanicity. Outcomes Patient care staffing levels, including ratios of RNs, licensed practical nurses (LPNs), patient care technicians (PCTs), composite staff (RN + LPN + PCT), social workers, and dietitians to in-center hemodialysis patients. Results After adjusting for background facility characteristics, ratios of RNs and LPNs to patients were 35% ( P < 0.001) and 42% ( P < 0.001) lower, respectively, but the PCT to patient ratio was 16% ( P < 0.001) higher in for-profit than nonprofit facilities (rate ratios of 0.65 [95% CI, 0.63-0.68], 0.58 [95% CI, 0.51-0.65], and 1.16 [95% CI, 1.12-1.19], respectively). Regionally, compared to the Northeast, the adjusted RN to patient ratio was 14% ( P < 0.001) lower in the Midwest, 25% ( P < 0.001) lower in the South, and 18% ( P < 0.001) lower in the West. Even after additional adjustments, the large for-profit chains had significantly lower RN and LPN to patient ratios than the largest nonprofit chain, but a significantly higher PCT to patient ratio. Overall composite staffing levels also were lower in for-profit and chain-affiliated facilities. The patterns hold when hospital-based units were excluded. Limitations Nursing hours were not available. Two part-time staff were counted as one full-time equivalent, which may not always be accurate. Conclusions The significant variation in patient care staffing levels and its associations with facility characteristics warrants inclusion in future large-scale hemodialysis outcomes studies. End-stage renal disease networks and hemodialysis facilities should attend to quality assurance and performance improvement initiatives that maximize licensed nurse staffing levels in hemodialysis fac