What is the best setting for receiving dialysis vascular access repair and maintenance services?



Advances in dialysis vascular access (DVA) management have changed where beneficiaries receive this care. The effectiveness, safety, quality, and economy of different care settings have been questioned. This study compares patient outcomes of receiving DVA services in the freestanding office-based center (FOC) to those of the hospital outpatient department (HOPD). It also examines whether outcomes differ for a centrally managed system of FOCs (CMFOC) compared to all other FOCs (AOFOC).


Retrospective cohort study of clinically and demographically similar patients within Medicare claims available through United States Renal Data System (USRDS) (2010-2013) who received at least 80% of DVA services in an FOC (n = 80,831) or HOPD (n = 133,965). Separately, FOC population is divided into CMFOC (n = 20,802) and AOFOC (n = 80,267). Propensity matching was used to control for clinical, demographic, and functional characteristics across populations.


FOC patients experienced significantly better outcomes, including lower annual mortality (14.6% vs. 17.2%, p<0.001) and DVA-related infections (0.16 vs. 0.20, p<0.001), fewer hospitalizations (1.65 vs. 1.91, p<0.001), and lower total per-member-per-month (PMPM) payments ($5042 vs. $5361, p<0.001) than HOPD patients. CMFOC patients had lower annual mortality (12.5% vs. 13.8%, p<0.001), PMPM payments (DVA services) ($1486 vs. $1533, p<0.001) and hospitalizations ($1752 vs. $1816, p<0.001) than AOFOC patients.


Where nephrologists send patients for DVA services can impact patient clinical and economic outcomes. This research confirmed that patients who received DVA care in the FOC had better outcomes than those treated in the HOPD. The organizational culture and clinical oversight of the CMFOC may result in more favorable outcomes than receiving care in AOFOC.

Post author correction


Article Subject: Dialysis




Audrey M. El-Gamil, Al Dobson, Nikolay Manolov, Joan E. DaVanzo, Gerald A. Beathard, Terry Foust Litchfield, Brook Cowin

Article History


Financial support and conflict of interest: The authors at Dobson DaVanzo & Associates, LLC report receiving financial support for conducting research using the USRDS claims and clinical information from Lifeline Vascular Access, a DaVita Healthcare Partners® affiliate. This funding source, beyond the identified authors, had no involvement in the study design; collection, analysis, and interpretation of data; writing the report; and the decision to submit the report for publication. The content expressed is the responsibility and opinion of the authors and not their affiliation.

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  • Dobson DaVanzo and Associates, LLC, Vienna, VA - USA
  • Lifeline Vascular Access, a DaVita Healthcare Partner ®, Vernon Hills, IL - USA

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