Comparative clinical and economic outcomes of peritoneal dialysis in urban teaching, urban non-teaching, and rural hospitals in the United States: a nationwide analysis from the National Inpatient Sample

Abstract

Objective: Hospital settings may influence outcomes and resource utilization in end-stage kidney disease (ESKD) patients receiving peritoneal dialysis (PD). However, data on PD outcomes across hospital settings remain limited. This study aims to evaluate characteristics, in-hospital treatments, complications, and healthcare costs for PD patients in urban teaching, urban non-teaching, and rural hospitals across the United States. Methods: We conducted a cohort study using the National Inpatient Sample database in the United States from 2003 to 2018. Multivariable logistic and linear regression models were employed to compare in-hospital treatment outcomes, mortality, and healthcare costs across hospital settings, adjusting for demographics, comorbidities, and hospital characteristics. Results: A total of 99,528 hospitalized ESKD patients receiving PD were included. Among these patients, 60,833 (61%) were in urban teaching hospitals, 32,714 (33%) in urban non-teaching hospitals, and 5,981 (6%) were in rural hospitals. In multivariable analysis, patients in urban non-teaching hospitals had lower risk of PD catheter adjustments (OR 0.81, 95% CI 0.68–0.97), hyperkalemia (OR 0.85, 95% CI 0.76–0.95), metabolic acidosis (OR 0.69, 95% CI 0.61–0.78), volume overload (OR 0.82, 95% CI 0.71–0.95), and mortality (OR 0.76, 95% CI 0.63–0.93) but higher risk of PD peritonitis (OR 1.25, 95% CI 1.15–1.36), and sepsis (OR 1.13, 95% CI 1.03–1.24), compared with urban teaching hospitals. Meanwhile, patients in rural hospitals had a lower risk of metabolic acidosis (OR 0.84, 95% CI 0.79–0.90) and volume overload (OR 0.82, 95% CI 0.76–0.89) but higher need for hemodialysis (OR 1.12, 95% CI 1.06–1.19), and risk of PD peritonitis (OR 1.18, 95% CI 1.13–1.24). Urban non-teaching and rural care were associated with lower hospitalization length of stays by 1.5 and 0.5 days and costs by $31632 and $10376, respectively. Conclusion: Rural and urban non-teaching hospitals experienced fewer metabolic complications and less volume overload but faced higher rates of PD-related peritonitis compared to urban teaching hospitals. These findings highlight clinical and economic differences in PD across hospital settings in the United States and crucial strategies for personalizing PD care and optimize resources. Future research should explore system-level interventions to enhance PD delivery in diverse healthcare settings.