Relative to the 2003 cohort of incident patients in freestanding dialysis facilities, there have been continued declines in the first-year mortality rate of successive cohorts of incident patients. Among patients who initiated dialysis during the first half of 2011, the first-year mortality rate was 26.0 deaths per 100 patient-years, down 15 percent from 30.6 deaths per 100 patient-years among incident patients during 2003. There are exceptions to the national trend. There has been no improvement in the East North Central region. With hospitalization rates also high in this region, concerns arise about not only the quality of care in dialysis facilities themselves, but also the quality of care in the broader healthcare delivery system, suggesting the need for careful attention at both the macroscopic level of state government and the microscopic level of dialysis facilities.