Higher Mortality Rates in For-Profit Dialysis Centers: Is it True?

[okarol]

From Medscape Nephrology > Berns on Nephrology
Higher Mortality Rates in For-Profit Dialysis Centers: Is it True?
Jeffrey S. Berns, MD LISTEN TO AUDIO: http://www.medscape.com/viewarticle/735200
Authors and Disclosures
Posted: 01/12/2011
 
Hello, this is Jeffrey Berns from the University of Pennsylvania School of Medicine in Philadelphia. I'm Editor-in-Chief of Medscape Nephrology. I recently came across a paper that was published in a journal called Health Services Research,[1] which looked at mortality outcomes in patients in for-profit compared with not-for-profit dialysis facilities, in a period of time between 2004 and 2006.

This particular study looked at 4 for-profit chains, which were not identified in the paper, but during the period the study dialyzed between 3400 and more than 10,000 patients. These 4 chains were compared with 1 not-for-profit chain, which dialyzed about 1400 patients, and then there were 2 collections (which were not very well described in the paper) of nonchain units that were for profit, and not for profit, that dialyzed smaller numbers of patients.

Before going any further, I should provide a disclaimer that the dialysis units affiliated with the University of Pennsylvania in which our faculty sees patients are owned by a large for-profit dialysis facility.

The findings of the study, which I should note, included patients who were a mix of prevalent and incident, although mostly prevalent, they had to have survived at least 90 days on dialysis, and the mix of prevalent and incident patients was not clear. They excluded patients with HIV infection.

The study period was 2004 to 2006, with a mean follow-up of 16 months. In their unadjusted analysis, mortality was 4%-21% higher in the various dialysis units compared with the reference group, which was the not-for-profit chain. In an adjusted analysis, 6%-24% higher mortality was observed. These differences for the most were either not statistically significant or of borderline statistical significance.

As you can imagine, the patient characteristics were hugely different in many respects across these different facilities, sometimes in favor of the for-profit facilities, sometimes in favor of the not-for-profit facilities, and it's very hard to sort out what differences between the patient populations and facilities might explain these findings. Previous literature in this area, clearly has identified, differences in patterns of treatment in dialysis facilities. One study, for instance, showed higher erythropoiesis-stimulating agent use, but also higher hemoglobin levels, T stats, and urea reduction ratios, but no differences in mortality. Other studies, with 1 exception, have not found differences in mortality.

The interesting question in my mind is, why, and is this real? Is it a patient characteristic issue? Is it a dialysis facility issue? Is it even a real observation? When one applies a variety of statistical techniques to try to correct for what are very different demographic and clinical features among patients at dialysis facilities of different sizes and different geographic locations, it's very difficult to tease out whether there really is a meaningful or significant and important mortality difference between for-profit and not-for-profit facilities.

This is obviously very important, given the increasing trend towards large chains that are for-profit, so it's an interesting study. It's retrospective; it's observational, and it's provocative. It requires further study to better understand whether this is a real observation and the implications for it. It would be an interesting study to compare what happens to patient outcomes in a particular facility that converts from not-for-profit with for-profit or in the other direction, although I'm not sure that many facilities could be studied with that kind of format, but it would be interesting.

If you have any particular comments about this, please submit them through the Medscape Webpage. I hope everyone had a happy holiday. Take care now. This is Jeff Berns from the University of Pennsylvania School of Medicine in Philadelphia.

[greg10]

From Medscape Nephrology > Berns on Nephrology
Higher Mortality Rates in For-Profit Dialysis Centers: Is it True?
Jeffrey S. Berns, MD LISTEN TO AUDIO: http://www.medscape.com/viewarticle/735200
Authors and Disclosures
Posted: 01/12/2011
 
Hello, this is Jeffrey Berns from the University of Pennsylvania School of Medicine in Philadelphia. I'm Editor-in-Chief of Medscape Nephrology. I recently came across a paper that was published in a journal called Health Services Research,[1] which looked at mortality outcomes in patients in for-profit compared with not-for-profit dialysis facilities, in a period of time between 2004 and 2006....

Thanks for the article.
It is not clear which paper Dr. Berns is reading, because the reference [1] which he cited in Medscape is the following:
[1]Lee DK, Chertow GM, Zenios SA. Reexploring differences among for-profit and nonprofit dialysis providers. Health Serv Res. 2010;45:633-646.
http://www.hsr.org/hsr/abstract.jsp?aid=45768084902

Reexploring Differences among For-Profit and Nonprofit Dialysis Providers

Donald K. K. Lee, Glenn M. Chertow, Stefanos A. Zenios
Health Services Research VOLUME 45 | NUMBER 3 | JUNE 2010

Objective. To determine whether profit status is associated with differences in hospital days per patient, an outcome that may also be influenced by provider financial goals.

Data Sources. United States Renal Data System Standard Analysis Files and Centers for Medicare and Medicaid Services cost reports.

Design. We compared the number of hospital days per patient per year across for-profit and nonprofit dialysis facilities during 2003. To address possible referral bias in the assignment of patients to dialysis facilities, we used an instrumental variable regression method and adjusted for selected patient-specific factors, facility characteristics such as size and chain affiliation, as well as metrics of market competition.

Data Extraction Methods. All patients who received in-center hemodialysis at any time in 2003 and for whom Medicare was the primary payer were included (N=170,130; roughly two-thirds of the U.S. hemodialysis population). Patients dialyzed at hospital-based facilities and patients with no dialysis facilities within 30 miles of their residence were excluded.

Results. Overall, adjusted hospital days per patient were 17±5 percent lower in nonprofit facilities. The difference between nonprofit and for-profit facilities persisted with the correction for referral bias. There was no association between hospital days per patient per year and chain affiliation, but larger facilities had inferior outcomes (facilities with 73 or more patients had a 14±1.7 percent increase in hospital days relative to facilities with 35 or fewer patients). Differences in outcomes among for-profit and nonprofit facilities translated to 1,600 patient-years in hospital that could be averted each year if the hospital utilization rates in for-profit facilities were to decrease to the level of their nonprofit counterparts.

Conclusions. Hospital days per patient-year were statistically and clinically significantly lower among nonprofit dialysis providers. These findings suggest that the indirect incentives in Medicare's current payment system may provide insufficient incentive for for-profit providers to achieve optimal patient outcomes.