Study faults care at Fayetteville dialysis clinics

Published: 06:14 AM, Sun Sep 04, 2011
Study faults care at Fayetteville dialysis clinics

By Jennifer Calhoun
Staff writer

The patient death rates at three of Fayetteville's four private, for-profit dialysis clinics are significantly higher than the national average.

Patients of Fresenius Medical Care South Ramsey, Fresenius Medical Care North Ramsey and Fayetteville Kidney Center on Owen Drive are also much more likely to be hospitalized for blood infections.

Those are among the findings by the Centers for Medicare and Medicaid Services, which studied death and infection rates at the nation's private dialysis clinics.

Only one private clinic in the city, Fresenius Medical Care of West Fayetteville, performed better than the national average in terms of death rates and the same as the national average in infection rates, according to the center's statistics.

All four clinics are owned by the same corporation, Fresenius Medical Care North America, one of the largest dialysis companies in the country.

Fresenius owns about 1,800 dialysis clinics in the U.S., and many have performed well. But at the three Fayetteville clinics, death rates between 2006 and 2008 were worse than expected for patients, given their age, race, ethnicity, gender, duration of end-stage renal care, nursing home status, body mass index and other factors.

According to ProPublica, an investigative journalism group that created a database for the Centers for Medicare and Medicaid Services, the death rate at Fayetteville Kidney Center was 21 percent worse than expected. At FMC South Ramsey, the outcome was 44 percent worse than expected.

FMC North Ramsey had a 50 percent worse-than-expected death rate.

Fayetteville Kidney Center, FMC South Ramsey and FMC North Ramsey also showed higher rates of hospitalization for septicemia - life-threatening blood infections - than the state and national averages, according to the ProPublica database.

Infection risks
Infections are one of the major causes of death in patients with kidney disease, according to a 2010 study headed by Dr. Alexander Kallen, a medical epidemiologist with the Centers for Disease Control and Prevention.

During hemodialysis, the most common form of dialysis, blood is removed and cleaned of waste, then put back into the body.

It can be a vulnerable time for patients, who could suffer blood infections or infections at the portal where the blood leaves and enters the body.

Patients take dialysis once their kidneys have failed, often because of diabetes or high blood pressure. Other conditions, such as Lupus or trauma, also can lead to kidney failure.

Patients usually take three- to four-hour hemodialysis treatments three times a week. The average annual cost of dialysis is about $65,000 per patient.

Experts in the industry say poor infection-control practices and a high number of elderly patients or patients with significant health problems could contribute to the high death and infection rates at dialysis clinics.

Officials with Fresenius Medical Care North America say the high rates at its three Fayetteville clinics could be the result of a large number of elderly patients and patients with additional health problems. They said poor infection-control procedures or patient safety practices are not to blame.

But state inspection reports show that all three clinics have had recurring problems.

The state is contracted by the Centers for Medicare and Medicaid Services, the federal agency that administers Medicare, Medicaid and the Children's Health Insurance Program, to inspect the clinics at least once every three years or when a complaint is made.

State records show that each of the three Fayetteville clinics was inspected several times between 2006 and 2010.

Among the findings at the South Ramsey clinic:

Patients were not encouraged to use gloves when touching their portals.

A staff member failed to wear gloves when touching a patient's dialysis machine.

Medications that were to be used on various patients were stored in the dirty sink area.

No hot water was available in sinks that were supposed to be used for patients to wash their hands.

No documentation of caring for or changing the dressing on a patient's catheter over the course of four treatments.

The most recent state inspection at the South Ramsey clinic, in March, found more deficiencies, including jugs to hold an acid concentrate used for dialysis had "dime-sized brown-colored smears on the exterior" and "dirt residue" around the bottoms. The jugs were found to have been cleaned outside using a garden hose.

The same month, the clinic was cited for failing to properly monitor a patient with low blood pressure. The patient fell during a treatment and injured her head and eye.

At the North Ramsey clinic, an inspector found in June 2008 that the physician-director failed to ensure staff properly monitored the signs and symptoms of infection in a patient. The patient wound up in the hospital with a fever of 104 degrees.

Later that year, the staff failed to correctly administer antibiotics to a patient who had been hospitalized for drug-resistant Staphylococcus aureus, or MRSA.

In May at the same clinic, a state inspector witnessed bags of dirty saline draining in a sink used for hand washing.

At Fayetteville Kidney Center, state investigators found in January and August of 2007 that the clinic was not adequately staffed to meet the patients' medical needs.

One patient interviewed by an investigator said she had to administer many of her own dialysis applications herself because of the lack of available staff.

At the same clinic in February 2010, a patient who was holding his portal with his bare hands told a state inspector that the staff had never offered him gloves.

Jane Kramer, spokeswoman for Fresenius North America, said all three clinics remedied the problems and implemented corrective actions after each infraction.

Kramer denied that the infractions resulted from recurring problems.

"Usually the inspection reports identify items and infractions that can be corrected rapidly, and they are corrected as quickly as possible, if possible," Kramer said in an email. "Please don't conclude that an infraction noted implies a pattern of behavior."

Kramer said the clinics served a higher number of elderly patients and patients with catheters, which are more readily infected than other types of portals.

"We have many patients in their late 70s, and in their 80s and 90s in those two clinics," Kramer said.

Patients who received treatments through catheters are known to experience a higher infection rate than those who have an arteriovenous fistula.

A catheter is a tube that's inserted into a vein, the chest, the neck or groin. Catheters have two chambers that allow for a two-way flow of blood. They do not require a needle to be inserted.

A fistula is surgically created by connecting an artery to a vein, usually in the forearm.

The connection causes more blood to flow into the vein, making the vein larger and stronger so repeated needle insertions for hemodialysis treatments are easier. Fistulas are less likely to form clots or become infected than catheters.

Newer dialysis patients may not have fistulas because the site takes months to develop after the surgery.

According to the Centers for Medicare and Medicaid Services data, the number of patients with catheters at the three Fayetteville clinics was higher than the national average and a lower percentage had fistulas.

While the center factors age and poor health into its data, experts are not always able to capture all the illnesses and problems associated with a patient's health, said Dr. Abhi Kshirsagar, a nephrologist with the UNC Kidney Center and an associate professor at the University of North Carolina Medical School.

"I'll tell you, just from experience, mortality figures are difficult to disentangle," Kshirsagar said.

Size of clinic
The three Fayetteville clinics also shared another risk factor: Their size.

The clinics are among the largest in the state, which Kshirsagar said could jeopardize patient care.

FMC North Ramsey has 40 patient stations, and Fayetteville Kidney Center has 39. FMC South Ramsey maintains 51.

In contrast, FMC of West Fayetteville, which had better patient outcomes, maintains 33 patient stations.

An average dialysis clinic has about 22 patient stations.

"There's a point at which there are just too many patients in one particular clinic," Kshirsagar said. "That makes it difficult for nursing staff. Having seen patients at large clinics and small clinics, I feel like I have a lot more control and much more time to talk with patients at the smaller clinics."

Bill Peckham, a Seattle-based dialysis patient advocate and longtime dialysis patient himself, agreed.

"A lot of times in these big practices, the doctors are not actually going to see these patients," Peckham said. "They're kind of these walk-bys. You need that 10 or 15 minutes of privacy where you can speak candidly about what's going on. It's really not at all optimal."

The size of the staff also plays a big part in patient care, Kshirsagar said.

"The higher the ratio of nurses to patients, the better the outcomes will be," he said."

If staff turnover is high, "that certainly contributes to worse outcomes," he said.

Kramer said the Fayetteville clinics have a retention rate of about 80 percent. The average retention rates nationally for Fresenius clinics is 85 percent, she said.

Burnout for dialysis technicians can be high, Kshirsagar said.

Kimberly McLean-Ray, a Fayetteville native, said she has watched burned-out workers provide lax - and sometimes dangerous - treatment.

McLean-Ray was 23 in June 2005 when she started dialysis treatments at Fresenius Medical Care on North Ramsey Street.

"To call it a life-changing experience was an understatement," she said. "I guess I didn't realize how sick I was."

She said her treatments sometimes started an hour to an hour-and-a-half late, and there was a high turnover rate among employees.

She said the employees often seemed rude or frustrated.

"There was never consistency in the staff," she said. "New people were always coming in, and people were always leaving."

Other clients said they have had good experiences.

Collin Arrington, a retired Army major, said he had the choice of leaving FMC South Ramsey for the new Fayetteville Veterans Affairs dialysis clinic. He chose not to change because of the staff members who work with him.

"I've been there three years now, and I've established a routine," said Arrington, who is 57. "I'm getting quality treatment, and why would you change something if you're already getting good care?"

Lucrative business
Despite poor patient outcomes at some clinics, big dialysis corporations, including Fresenius Medical Care, increased revenue and made profits in the hundreds of millions of dollars during the first quarter of this year.

In 2010, Fresenius made a net profit of $979 million. The company expects a net profit this year of between $1.04 billion and $1.06 billion.

One reason could be that dialysis patients are almost always insured, which means few - if any - nonpaying customers.

Since 1973, Medicare has insured many dialysis patients regardless of age.

While Medicare is usually reserved for people 65 and older or with disabilities, it also covers people of any age with end-stage renal disease.

As of April 4, when the latest Centers for Medicare and Medicaid Services data was available, Medicare covered dialysis treatments for 538 patients in Cumberland County and 14,038 in the state.

But Medicare does not reimburse as much as private insurers, Kshirsagar said. And Fayetteville doesn't have as many privately insured patients as cities in other parts of the state or the country.

At Cape Fear Valley Health System, officials say that more than 70 percent of patients use some type of government insurance - Medicare, Medicaid or Tricare - all of which use similar reimbursement rates.

The standard is about 40 percent Medicare and Medicaid and 30 percent privately paid, said Jack Ahern, a health care consultant and columnist for "Renal Business Today."

To add to the problem, Medicare reimbursements for dialysis procedures were bundled this year, making some payments lower, Kshirsagar said.

Lower payments could mean that more clinics might be reluctant to take on new Medicare patients, Kshirsagar said.

It could also mean a lower quality of care, Peckham said.

Ahern said Medicare pays about $250 for each dialysis session, which includes drugs and supplies associated with the treatment.

Private insurers tend to pay more. A lot more.

Blue Cross and Blue Shield of North Carolina's average claims charge for the same treatment is about $6,000 in Fayetteville, said Lew Borman, a spokesman for Blue Cross.

"It's basically out of this world," Peckham said. "They figure out what your insurance will pay, and that's what they charge. Unless you have bargaining power, you're about to get raked over the coals."

If a clinic has more money coming in, Peckham said, it could translate to higher staff ratios and better clinical oversight.

"They're differentiating between private payers and Medicare payers more and more," he said. "It's not right, but that's what's happening."

FMC of West Fayetteville, which performed better than the city's other three clinics, had a somewhat higher percentage of clients with private insurance, Kramer said.

"But this is a function of geography," she said. "Patients tend to dialyze closest to where they live."

Finding the cause
Ahern, the health care consultant, said patient outcomes at the Fayetteville clinics can be improved, but it would require an extensive look at what's causing the problems.

"You have to get underneath the superficiality of numbers and find out what's causing this," he said. "In an ideal world, I would have a third party come in with no bias."

It's a worthy mission, too, Ahern said.

"In my opinion, dialysis is the best of what medicine has to offer," he said. "In some cases, it's letting people get a transplant and start a brand new life. It lets people live."

Staff writer Jennifer Calhoun can be reached at calhounj@fayobserver.com or 486-3595.

http://www.fayobserver.com/articles/2011/09/04/1116682?sac=Home