# Balancing efficiency and clinical quality in dialysis centers: Insights from a nationwide DEA study in Taiwan

## TL;DR

This study examines how dialysis centers in Taiwan balance efficiency and clinical quality, finding that higher efficiency may sometimes lower certain quality indicators.

## Contribution

The study introduces a systems-based DEA framework to evaluate efficiency-clinical quality trade-offs in dialysis centers.

## Key findings

- Higher efficiency scores correlate with lower dialysis adequacy and higher Ca × P values.
- Chain-affiliated and for-profit centers show better clinical outcomes compared to non-profit and independent centers.
- DEA is shown to be a useful tool for evaluating dialysis center performance at a system level.

## Abstract

The increasing prevalence of end-stage renal disease (ESRD), especially in aging populations, presents significant challenges for healthcare systems. Dialysis centers must navigate growing demands for cost efficiency while maintaining high-quality care. This study aimed to evaluate the relationship between operational efficiency and clinical quality in dialysis centers, using a systems-based performance assessment framework.

We analyzed 578 dialysis centers in Taiwan using Data Envelopment Analysis (DEA) to estimate operational efficiency. Clinical quality was assessed using outcome indicators including mortality rate, dialysis adequacy (urea reduction ratio [URR], Kt/V), serum albumin and hemoglobin levels, calcium-phosphate (Ca × P) product, and cardiothoracic ratio. Multiple regression analyses were conducted to examine associations between efficiency scores, clinical outcomes, and organizational characteristics, including chain affiliation and ownership type.

Higher efficiency scores were significantly associated with lower URR, Kt/V, and Ca × P values, suggesting potential trade-offs between operational efficiency and clinical quality. Centers affiliated with chains generally reported better clinical outcomes. For-profit centers exhibited higher URR, Kt/V, and albumin levels, as well as lower Ca × P values, compared to their non-profit counterparts.

Operational efficiency in dialysis centers may come at the cost of certain clinical outcomes. However, organizational characteristics such as chain affiliation and for-profit ownership are linked to better quality indicators. These findings highlight the value of DEA as a tool for system-level performance evaluation and inform strategies to optimize dialysis care delivery.