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Health care is local, personalized, and as a result, can be highly variable. But with the advent of service design thinking, process improvements, and clinical informatics, it is possible to consistently provide high-quality care — improving the efficacy, efficiency, and safety of health care at scale.

Most quality frameworks are national in theory but local in implementation, creating variance. Hospital chains, oncology, and dialysis providers are some of the few, nationally scaled providers in health care today. Among these, dialysis care has successfully demonstrated the ability to effectively scale a high-quality standard for patients treating at home and in a facility. That corresponds with larger gains in patient survival than cancer, diabetes, heart failure, and stroke.1

Caring for end stage kidney disease

Approximately 786,000 Americans are living with kidney failure, also known as end stage kidney disease (ESKD), and require a kidney transplant or dialysis to sustain life. While transplantation remains the best and most cost-effective treatment option for most ESKD patients, there are simply not enough viable organs to meet current need. In the absence of a transplant, dialysis does mechanically what the kidneys can no longer do — remove waste and extra fluid from the bloodstream.

Because our patients are medically complex, the kidney care community was the first to embrace a pay-for-performance system, moving from a fee-for-service model to one that rewards outpatient dialysis facilities for meeting specific quality measures. This value-based approach has dovetailed with the dramatic reduction in death rates among dialysis patients, as well as hospitalization rates and total cost of care.1

Across the country, DaVita® medical facilities support in-center and home dialysis patients with the same clinical expectations, employ the same clinical protocols, and provide clinicians with the same training. Our care teams are trained to deliver safety and quality at every step, giving them greater ability to positively impact clinical outcomes and reduce health care-acquired infections. As part of this, we’ve created equitable access to education on all modality options, including transplant and home dialysis. This education empowers patients to choose the modality that is right for them and to successfully stay on their treatment of choice for longer. Today, more than 15% of DaVita patients treat at home.

This standardization of care at scale creates more opportunity to systematically identify trends, fix deficiencies, and elevate the care experience for patients who receive dialysis — whether in a center or at home — three times per week for up to four hours per treatment. And this commitment to continually improving dialysis care is something nephrologists and providers work together to achieve.

Quality in dialysis care is reflected in three key areas

  1. Improved survival rates

Between 2001 and 2016, the last year for which complete data are available, all-cause mortality for ESKD patients decreased by more than 29%.1 Survival rates have improved across all ages, genders, and dialysis modalities.1

This is incredible — especially when one considers that dialysis providers are caring for more patients than ever before, and patients are in worse health when they start dialysis2 than in previous decades. As a kidney care community, we invest heavily in research and use our findings to help improve every detail of care delivery. For other disease states like cancer, clinical improvement largely comes from new therapeutics. In dialysis, improved outcomes have been almost entirely a result of improvements in care practices.

  1. Reduced health care utilization

Inpatient hospitalization is a main driver of health care costs in the United States.

Over a nine-year period, hospitalization rates for dialysis patients fell over 14%,1 with cardiovascular related hospitalizations — the most common cause of morbidity in ESKD patients — declining 18.9%. This means our patients are spending more days at home and more time doing what they love.

Several factors influence the advances in dialysis care that have led to reductions in hospital admissions, average length of hospital stays, complications, and readmissions.

The first is optimal dialysis starts. In dialysis, a physical access connects a patient’s body to treatment. While this is critical, accesses can create an opportunity for infection and subsequent hospitalization in certain cases. For this reason, we have focused on setting patients up for success regardless of the type of access placed and where they treat — in a center or at home. In fact, hospitalizations due to vascular access infections among in-center dialysis patients have fallen by more than half through this work.1

Secondly, by leveraging personalized care models and innovative technology, dialysis clinicians are better able to predict the likelihood of patient hospitalization. DaVita has built industry-leading, large-scale data sets containing billions of patient data points. These predictive algorithms help pinpoint the delivery of the right care at the right time, with earlier outpatient interventions affording patients quality of life opportunities that may not have been possible a decade ago.

  1. Lower costs

Medicare spends nearly $120 billion a year on patients with kidney disease, with the majority of these costs allocated to hospitalizations and managing multiple comorbidities.3

While an eye-popping amount, per capita Medicare spending for dialysis has fallen more since 2007 than spending on care for other chronic conditions when adjusted for inflation.4 When dialysis care is tied to meeting quality performance measures, such as fewer hospitalizations and reduced need for emergency care, the total cost of care decreases. All told, better dialysis care is saving taxpayers billions of dollars.1

No quality improvement program can be successful without patient engagement. Dialysis patients receive treatment from care teams they know, trust, and see weekly. At every interaction, they are equipped with education to better understand kidney disease and modality options, connected to social workers to help address emotional wellness concerns, and empowered to participate in shared decision-making with their clinicians. This is patient-centered care in action.

The output of scaled, quality efforts to reliably deliver excellent dialysis care may be clear, but our work isn’t complete. We must apply actionable insights to solve other complex problems across kidney care, such as addressing disease risk factors, early diagnosis, modality education, and expanding access to kidney transplantation. That’s why we are dedicated to continuing our pursuit of quality at every step of the kidney care continuum.

Learn more about DaVita’s commitment to safety and high-quality care at

Mahesh Krishnan, MD, MPH, MBA, FASN, is group vice president of research and development for DaVita Kidney Care and serves as the clinical lead for DaVita Venture Group. He can be reached at [email protected]


  1. United States Renal Data System. 2018 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2018.
  2. Jonathan Himmelfarb, M.D., T. Alp Ikizler, M.D. Hemodialysis. New England Journal of Medicine 2010; 363:1833-1845. doi: 10.1056/NEJMra0902710.
  3. USRDS Annual Data Report 2020, Figures 9.8, 6.1; 2018
  4. CMS Chronic Conditions: Utilization/Spending State Level: All Beneficiaries, 2007-2015. Accessed at