Javier J. Rodriguez
Chief Executive Officer, DaVita Inc. at DaVita
Thank you, Nic, and thank you all for joining our call today. Through the first quarter, we continued building on the momentum generated through 2023, demonstrating operational discipline while continuing to find opportunities to invest, innovate and most importantly, deliver clinical excellence. Today, I will cover our first quarter results, provide color on our expanding international business and wrap up with an update on Change Healthcare claim disruption.
Before we get into our first quarter performance, I'll start as we always do with a clinical highlight. One of our strategic goals is to provide solutions for patients at every stage along the kidney care journey, including helping to support transplantation. Our aspiration is to enable as many patients as possible to receive this life-changing gift. Let me highlight three ways that DaVita is helping to address the systemic challenges of kidney transplant. The first is patient referrals to transplant centers. We recently achieved our highest monthly rate with more than 2/3 of DaVita patients under the age of 75 years old being referred for transplant.
The second is living donation. The number of living donors in the United States has essentially been flat over the past two decades. To encourage more living donors, we partnered with the National Kidney Foundation on its Big Ask, Big Give campaign to educate the community on living donation. We also offered patients a range of resources to support them through the conversations about living donation. And finally, because there is a gap on transplant rates across race and ethnicity, we created a new Health Equity Learning Lab.
By deploying transplant navigators, we're testing novel approaches to drive a more equitable distribution of patients succeeding on their quest to receive a transplant. Through these and other efforts, more than 8,000 DaVita patients received a kidney transplant in 2023, the highest number of annual transplant in our history. Unfortunately, the largest challenge continues to be constrained organ supply. You may have seen recent stories about compassionate care cases involving genetically engineered-pig kidneys. This is an exciting first step as society aspires to a future where organ availability is no longer a constraint for patients living with kidney disease. It is still in its early days for this technology as human trials will take some time.
In the meantime, we will continue to invest in transplant and participate in innovations that will improve access to this life-changing outcome. Transitioning to our first quarter performance. Adjusted operating income was $463 million, and adjusted earnings per share from continuing operations was $2.38. We had a strong quarter across our core financial trilogy with treatment volume and patient care costs performing in line with our expectations and incremental upside driven by revenue per treatment. Our Q1 performance provided increased confidence in our full year expectations, and therefore, we're raising the bottom of our adjusted operating income guidance putting our updated range at $1.875 billion to $1.975 billion.
Within these consolidated results, our international business is a growing piece of DaVita's portfolio. As a reminder, our international strategy is focused on three primary principles, first, identify markets that enable us to invest in clinical differentiation and provide excellent standards of care to our patients. Second, operate in countries where we have a path to achieve meaningful scale led by strong local management teams. And finally, hold ourselves to the same discipline of capital-efficient growth and attractive risk-adjusted returns that we use for all of our business segments.
Following these principles, in March, we signed an agreement to invest $300 million to expand our operations in Brazil and Colombia and enter Chile, and Ecuador through the acquisitions of high-quality centers in those four markets. The Chile acquisition has closed and the transaction in Ecuador, Colombia and Brazil remains subject to each country's respective antitrust and regulatory approval process, which we expect to be completed at various times throughout 2024. Opportunistic transactions such as this one are consistent with our overall enterprise capital allocation strategy.
Going forward, we will continue to monitor the market for acquisition opportunities that meet our investment criteria and we otherwise expect international investment to be roughly consistent with our historical levels. Upon completion of these transactions and combined with our existing business, we would be the largest dialysis provider in Latin America. Once these acquisitions close, we will provide care in 13 countries outside the United States with more than 500 centers treating approximately 80,000 patients and employing nearly 20,000 health care professionals.
In 2024, we expect international growth to contribute approximately $20 million or about one percentage point to DaVita's overall enterprise growth in adjusted operating income. Most importantly, our international clinical outcomes continue to excel. We outperformed the clinical benchmarks of every international market in which we operate, and we have reduced hospitalizations across all countries by 11% since 2021, which has driven a reduction in unnecessary health care expense and represents a meaningful improvement to our patients' lives.
And finally, let me cover our experience with the Change Healthcare outage and where we stand today. Historically, the vast majority of our U.S. dialysis claim went through the Change platform. Similar to many providers, this presented a challenging situation in the back half of Q1 as we were unable to submit claims through this channel. As reflected in our first quarter balance sheet, the increase in our days sales outstanding and borrowing on our revolving credit facility were entirely related to the Change outage. Joel will provide more detail, but to summarize, we have resumed billing activity, and we're collecting cash well in excess of our typical levels as we catch up from the claims backlog. As of today, we believe that the operational impact from the Change Healthcare disruptions are largely resolved.
I will now turn it over to Joel to discuss our financial performance and outlook in more detail.
