Patient Care Staffing Differs Markedly Between Nonprofit and For-Profit Hemodial

Reuters Health Information
Patient Care Staffing Differs Markedly Between Nonprofit and For-Profit Hemodialysis Centers
Jul 11, 2013
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NEW YORK (Reuters Health) Jul 11 - Nurse to patient ratios are significantly lower at for-profit hemodialysis facilities than at nonprofit hemodialysis facilities, according to a cross-sectional study of 4,800 U.S. hemodialysis facilities.

Nurse staffing mix in hemodialysis facilities may contribute to patient outcomes, so this must be considered when evaluating and addressing outcome disparities between different facilities.

As a start to exploring this issue, Dr. Guofen Yan from the University of Virginia School of Medicine, Charlottesville, Virginia, and colleagues used data from the Centers for Medicare & Medicaid End-Stage Renal Disease (ESRD) Facility Survey to examine the variation in nurse staffing levels across U.S. hemodialysis facilities and its association with facility characteristics and geographic region.

Dr. Virginia Wang from Duke University Medical Center, Durham, North Carolina, who studies the organization of healthcare and health policy, told Reuters Health in an email, "No study has empirically examined the relationship between dialysis facility staffing and patient outcomes/quality of care. What this paper represents is a first step toward such work."

After controlling for facility size, urban/rural location, and functional type (in-center only or in-center plus home dialysis), the number of RNs was 35% lower and the number of LPNs was 42% lower in for-profit centers than in nonprofit facilities (p<0.001 for both).

In contrast, the number of unlicensed patient care technicians was 16% higher at for-profit vs nonprofit facilities (p<0.001), according to the July 1 online report in the American Journal of Kidney Diseases.

For-profit centers had 8% fewer dietitians and 7% fewer social workers than nonprofit centers had (p=0.001).

There were significantly fewer nurses, dietitians, and social workers and significantly more patient care technicians in freestanding facilities than in hospital-based facilities.

In another comparison, all three large for-profit chains (DaVita, Fresenius, and Renal Advantage Inc.) and the small chains had significantly fewer RNs and LPNs and significantly more patient care technicians than did the largest nonprofit national chain (DCI).

There were also regional differences in staffing, but the differences above persisted after adjusting for them.

"Future studies that examine dialysis patient outcomes should include processes of dialysis care, quality of life, medical conditions, socioeconomic influences, and facility staffing ratios to better understand the unique interactions of these elements," the authors conclude.

"This will provide the requisite foundation for better understanding of optimal staffing ratios and the impact of different health care providers in various dialysis facility settings," the researchers explain. "The CMS, ESRD networks, and hemodialysis facilities should attend to the policies, regulations, and performance improvement initiatives that support advancing the role of and exploring the relationship between dietitians, social workers, and licensed nurses in structurally different hemodialysis facilities."

Dr. Wang added, "This study is bringing attention to the concerns about healthcare provider staffing levels and quality of care that have been examined in hospitals and nursing homes, but have been relatively understudied in the dialysis industry."

"Another thing to consider," she continued, "is that this study examines dialysis staffing as it existed in 2009. While reimbursement for dialysis treatment services has remained equal (regardless of dialysis treatment modality) since 1983, the new structure of the payment - what's known as ESRD bundled payment - has undergone significant change since 2009. Although the equal payment concept remains the same, the new payment structure may strain dialysis facility operations in a way that impacts dialysis facilities' staffing levels today."

A special article in the same issue of American Journal of Kidney Diseases, by Dr. Richard A. Hirth from University of Michigan, Ann Arbor, Michigan, and colleagues, looks at the impact of Medicare's new prospective payment system for kidney dialysis. Although it does not address staffing, it demonstrates that the incentives supported by this new system "seem to have motivated dialysis providers to move toward lower cost methods of care in both their use of drugs and choice of modalities."

Dr. Yan did not respond to a request for comments on this report.

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http://www.medscape.com/viewarticle/807735