Patient Care Technician Staffing in US Hemodialysis Facilities: An Ecological Study

Rationale & Objective: Technicians caring for patients receiving dialysis play a critical, frontline role in the care of patients receiving dialysis in the United States. We sought to provide a comprehensive description and identify correlates of US in -center hemodialysis facility patient care technician staffing patterns. Study Design: This was an ecological study. Setting & Participants: US facilities providing hemodialysis and reporting patient care technician staffing, identified using the US Renal Data System. Exposures: Geography, year, and facility characteristics, including aggregated patient characteristics. Outcomes: The study outcome was facilityreported patient -to -patient care technician ratio. Analytical Approach: We examined patient -topatient care technician ratios by US state and over time and also estimated the differences in patient -to -patient care technician ratios associated with facility characteristics, using robust regression with adjustment for facility -level covariates. Results: The median patient -to -patient care technician ratio among 6,862 US facilities in 2019 was 9.9 (25th -75th percentiles, 8.2-12.0). Median 2019 patient -to -patient care technician ratios varied substantially by US state and region. There was an overall decline (from 10.6 to 9.9) in median patient -to -patient care technician ratios from 2004 to 2019, whereas the percentage of positions that were unfilled increased (from 2.8% to 3.5%). After adjustment, large dialysis organization status (6, -0.42; 95% CI, -0.61 to -0.23) and larger facility size (6, -0.51; 95% CI, -0.68 to -0.33) were associated with lower patient -to -patient care technician ratios. Higher patient -to -registered nurse (6, 0.80; 95% CI, 0.65-0.9 4) and patient -to -social worker (6, 0.53; 95% CI, 0.37-0.70) ratios, presence of licensed vocational nurses or licensed practical nurses at the clinic (6, 0.83; 95% CI, 0.53-1.12), and location in a poverty area (6, 0.29; 95% CI, 0.130.4 4) were all associated with higher patient -topatient care technician ratios. Aggregated patient characteristics of patients treated at the facilities were generally not associated with patient -topatient care technician ratio after adjustment. Limitations: Limited causal inference and potential shifts in staffing after 2019. Conclusions: US dialysis facilities vary considerably in their patient care technician staffing by geography, over time, and by various facility characteristics. Further investigation of US patient care technician staffing is warranted and could lead to better, more stable dialysis staffing, improved staff and patient satisfaction, and higher quality of care.