This project will examine the degree to which counties with a high population risk for end stage renal disease, defined by high diabetes prevalence, are served by dialysis providers. It will assess the accessibility and quality of services for end stage renal disease looking for disparities associated with rural residence and racial/ethnic population composition.

We will conduct a quantitative cross-sectional analysis of dialysis facility availability at the county level linked to potential community need.

• Facility addresses will be geocoded and assigned to counties for linkage to county-level population data.
• Facilities will be linked to information regarding quality scores using facility identification numbers.
• As many counties will contain multiple facilities, mean and median values will be calculated as necessary.
• Comparisons will be made based on level rurality as measured by Urban Influence Codes and across community need and racial composition of counties.
• Community need will be characterized as "high" if the county is in the top quartile for estimated diabetes or chronic kidney disease prevalence; otherwise, low.
• Need will be calculated separately for rural and urban counties as population and disease distributions may vary.
• Availability will be measured by count of facilities, count of stations, and the proportion of facilities offering in-center hemodialysis, in-center peritoneal dialysis, and home dialysis training.
• Quality of ESRD services will be assessed by whether the center offers after-hours services (greater patient flexibility), the percent of present patients waitlisted for a transplant (indicates encouragement of this option), the overall CMS star ranking (4-5 v lower), and the Consumer Assessment of Healthcare Providers and Systems Star ranking (4-5 v lower).