ProPublica Report Slams Dialysis Centers

Comment: A summary of the recent Atlantic/Propublica articles.

ProPublica Report Slams Dialysis Centers
By Todd Neale, Staff Writer, MedPage Today
Published: November 10, 2010

Lapses in cleanliness and safety are common in U.S. dialysis centers, according to a joint investigation by ProPublica, a news organization specializing in investigative journalism, and The Atlantic magazine.

The two news organization teamed up to dig into previously unreleased quality data collected by the Centers for Medicare and Medicaid Services (CMS) to explore why the U.S. spends more than almost any other country per dialysis patient, yet has one of the highest mortality rates.

The ongoing investigation and resulting stories, written by Robin Fields of ProPublica, can be found on ProPublica's website.

Fields and her colleagues reviewed thousands of inspection reports obtained via Freedom of Information Act requests and interviewed more than 100 patients, advocates, doctors, policymakers, researchers, and industry experts for the investigation, and the findings were bleak, according to Fields.

"At clinics from coast to coast, patients commonly receive treatment in settings that are unsanitary and prone to perilous lapses in care. Regulators have few tools and little will to enforce quality standards. Industry consolidation has left patients with fewer choices of provider. The government has withheld critical data about clinics' performance from patients, the very people who need it most," she wrote.

Although CMS has a Dialysis Facility Compare tool on its website, it does not contain detailed quality data, but rather "a watered-down version of the data," Paul Steiger, editor-in-chief of ProPublica, and Stephen Engelberg, managing editor of the news organization, wrote in an accompanying editorial note.

"[Patients] have no access to the government's underlying numbers that track whether death, hospitalization, and infection rates are above or below what is expected," they wrote.

Just days before publication of the investigation, however, CMS released all of the data, which ProPublica plans on posting to its website. Steiger and Engelberg credited the investigation with leading to the release of the information.

"The reasons CMS has given for withholding the information until now is that some measures are disputed or lack refinement," Fields wrote. "Regulators and providers can put the data in perspective, officials had said, but patients might misinterpret the information or see it as more than they really want to know."

In a review of inspection records for more than 1,500 clinics in California, New York, North Carolina, Ohio, Pennsylvania, and Texas from 2002 to 2009, Fields and her colleagues found that poor conditions were relatively common. In nearly half of the units, inspectors noted dirty or unsafe conditions, including dried blood in treatment chairs or on walls, floors, and ceilings.

Hundreds of clinics were cited for lapses in infection control, and dozens more were tagged for prescription errors.

The investigation also turned up cases in which staff at dialysis centers were monitoring more than the recommended number of patients and were allowing patients to soil themselves rather than interrupt dialysis for a bathroom break in the interest of turning patients over more quickly.

In a follow-up to the main story, Fields detailed some of the serious problems that can occur during dialysis when there are lapses, including the dislodgement of the blood tubes leading to catastrophic hemorrhage and death, although she acknowledged that such occurrences were rare.

Part of the problem, according to Fields, is that dialysis providers have been incentivized to consolidate due to government payment policies, which limits patient choice and denies "consumers the chance to use market power to push for better care."

Just two corporations -- DaVita and Fresenius Medical Care North America -- control the majority of U.S. dialysis clinics, making about $2 billion in operating profits combined each year. Each has at least 1,500 clinics and more than 120,000 patients. No other operator has more than 300 clinics, according to Fields.

The community of dialysis providers defended itself against its overall negative portrayal in the ProPublica/The Atlantic investigation.

Kidney Care Partners (KCP), which bills itself as a coalition of patient advocates, dialysis professionals, care providers, and manufacturers, said in a statement that the story "fails to give a full picture of kidney care in America and the progress that has been made."

The statement cited improvement in the maintenance of adequate blood levels, the removal of toxins from the body, the vaccination of patients to prevent infectious diseases, and the achievement of target levels of phosphorous and calcium in the body.

"These positive trends stem from improvements in care plan protocols and clinical best practices, advances in medicines and biologics, innovations in new dialysis technologies and offerings, and programs to increase fistula usage over catheters," KCP said.

"The kidney care community in America provides high quality care and is committed to continually improving care quality," it continued. "We look forward to working in partnership with all stakeholders in kidney care to continue advancing positive trends in patient outcomes and improved survival rates, kidney transplant rates, and the overall dialysis experience."

A spokesman for DaVita was less measured in his response to the story: "ProPublica's article is irresponsible journalism. The ESRD program is a role model in our healthcare system and a success story within Medicare -- the fact that it provides universal coverage, its unparalleled transparency and demonstrably improved quality year-over-year, decade-after-decade should be celebrated. While we are never satisfied and constantly striving for continuous improvement, it fails to accurately represent the significant gains made in the most critical areas of care."

Fresenius Medical Care North America said in a statement that it does not "think the stories fairly or accurately reflect the quality of great care that we provide day in and day out to our patients."

The company cited a survey it conducted of its patients, in which 93% reported a high level of satisfaction with their care.

"We're proud to operate in a highly regulated environment and we are committed to continuous quality improvement not just adhering to medical practice guidelines as well as local, state, and federal treatment standards and rules because where operationally and clinically feasible, we exceed such standards," the statement read. "Where deficiencies are noted, we quickly correct them and train to avoid repeat errors."

URL: http://www.medpagetoday.com/Nephrology/ESRD/23284