Dialysis Facility Characteristics and Variation in Employment Rates: A National Study

Background: Investigation of factors associated with variation in dialysis patient employment has focused primarily on patient-level factors. Little is known about facility-level factors that may be associated with patient employment.Design, setting, participants, and measurements: The ESRD Facility Survey (CMS-2744A) began in 2004 to collect counts of employed patients aged 18 to 54, in addition to dialysis unit census, types and timing of treatments offered, and staffing. Using the 2004 ESRD Facility Survey File, we investigated dialysis unit characteristics and facility employment rate of patients aged 18 to 54 in a logistic regression analysis that included hospital-based chronic renal care facilities, nonhospital renal disease treatment centers, independent special purpose renal dialysis facilities, and renal disease treatment centers.Results: Across all facilities, 18.9% of prevalent patients aged 18 to 54 were employed, but facility employment rates ranged from 0 to 100%. Facility employment rate was positively associated independently with availability of a 5 p.m. or later dialysis shift (odds ratio (OR) 1.54, 95% confidence interval (CI) 1.42 to 1.68), availability of peritoneal dialysis or home hemodialysis (HD) training (OR 1.19, 95% CI 1.11 to 1.28), and provision of frequent HD (OR 1.26, 95% CI 1.07 to 1.49), after adjusting for patient/social worker ratio, rurality of unit location, and unit size. In addition, patient receipt of Vocational Rehabilitation (VR) services was more often reported in facilities with higher employment rates.Conclusions: Promoting gainful employment among ESRD patients continues to be a quality improvement need. A dataset that allows adjustment for patient-level variables would facilitate increased understanding of the contribution of dialysis facility variables to patient employment.Gainful employment among “the maximum practical number of patients” was specified as a goal in 1986 Congressional legislation governing responsibilities of End-Stage Renal Disease (ESRD) Networks (1). ESRD Network Organizations, which function as liaisons between the federal government and providers of ESRD services (2), subsequently began to collect annual counts of employed patients in each dialysis facility within their respective Network geographic areas. Variation in facility employment rates and the association of these rates with facility characteristics has not been investigated, however.Studies of factors associated with variation in dialysis patient employment have focused primarily on patient-level factors, especially individuals’ educational background, occupational status before dialysis, treatment modality, and health status/comorbidity. Higher educational level and prior occupational status are the patient-level factors that have been most consistently identified as predictors of patient employment (3–8). A study by Rasgon et al. (9) showed, however, that facility-level variables may also influence patient employment status. The researchers found that blue-collar workers receiving dialysis in a facility that provided a multidisciplinary predialysis program designed to assist patients in maintaining employment were significantly more likely to continue employment than blue-collar workers who were treated at facilities that did not provide such a program.We undertook this study to examine the potential association of facility characteristics with variation in patient employment rates across dialysis facilities, using a national database. We investigated dialysis facility characteristics and aggregate employment within facilities of prevalent patients aged 18 to 54, as reported on the 2004 ESRD Facility Survey. The ESRD Facility Survey is completed annually for the Centers for Medicare and Medicaid Services (CMS) by all Medicare-approved facilities providing outpatient services to ESRD patients. In 2004, the survey began to collect aggregate information on the number of patients aged 18 to 54 in the facility and the number of patients aged 18 to 54 who were employed at the end of the calendar year, in addition to counts of patients entering and leaving the facility and counts of patients in specific treatment modality categories at the end of the survey period. The survey also annually captures several facility characteristics that are recognized as potentially relevant for patient employment, i.e., availability of a late dialysis shift (10), availability of home dialysis treatment options (11), provision of frequent hemodialysis (HD) treatment (12), and level of social worker staffing (13).