Does tax status impact outcomes in kidney care?

You just heard from your nephrologist that you are approaching Stage 5 chronic kidney disease and you need to start thinking about treatment options, including transplant, home dialysis, and in-center dialysis. He wants to be proactive and have a surgeon implant an AV fistula and have you go through a kidney education class.

He also wants you to visit the ABC dialysis center down the street and get a better understanding of the dialysis clinic environment. His practice is affiliated with this clinic, which is owned by a company that operates 100 other facilities across the country. He says the chain’s clinical outcomes are good. “Is it for profit?” you blurt out in the middle of his explanation. “Yes,” he replies. “Well, that’s going to be a problem,” you think to yourself.

Patients should be interested in the clinical outcomes of any facility that provides them with treatment, but what influence does for-profit status have on patient care?

Majority rules

A new study released this month in the Clinical Journal of the American Society of Nephrology concludes that patients treated by for-profit dialysis providers from 2005-2009 had a 15% higher likelihood of being hospitalized compared to patients treated by not-for-profit providers. The retrospective review is based on data from the U.S. Renal Data System, using a cohort of 150,642 patients; 12,985 (9%) were receiving care in nonprofit dialysis facilities.

The study authors also looked at hospitalization rates specifically linked to cases of heart failure or fluid overload, and found a 37% higher rate of hospitalization among for-profit clinics. They also found a 15% higher rate of hospitalization for vascular access complications. “Our findings highlight the need to examine whether there are processes of care that differ by profit status or organizational structure and whether these processes are modifiable risk factors for hospitalization, particularly among patients on hemodialysis,” they wrote. They suggested clinical areas like time on dialysis, cycler versus noncycler use for patients on peritoneal dialysis, management of volume and dry weight assessment, staffing models, physician practices, the culture of safety within dialysis facilities, and differences in preventive care within dialysis facilities could all be factors that may impact hospitalization.

Medicare should be interested in the results of this study: the agency spent 38% of its dollars directed toward the ESRD Program on inpatient care in 2010.

Bad vs. good care

The study authors acknowledge some limitations of their research. The analysis of data from 2009 doesn’t account for quality improvement efforts among all providers that may narrow the gap (the introduction of the Quality Incentive Program and recent results from the Performance Excellence and Accountability in Kidney Care study showing a 13% drop in first-year mortality among all providers come to mind). “Since 2009, practices have continued to evolve, “ the authors acknowledge, “with large for-profit dialysis organizations implementing quality improvement initiatives focused on extracellular volume management, reduction of tunneled dialysis catheter use, and the expansion of programs that focus on the first 120 days of dialysis as a high-risk period.”

What impacts outcomes?

Clearly, for-profit dialysis operates the majority of dialysis clinics in the United States. Dialysis Clinic Inc. and Northwest Kidney Centers are the most widely known not-for-profit providers. We want to know what DCI and Northwest Kidney are doing differently.

Part of that answer may lie in the focus of our cover story this month: removing the barriers and placing more patients on home therapy. Data show, for example, that peritoneal dialysis may be more cost effective as a therapy to administer. But patients on PD or on home hemodialysis also tend to be healthier and spend less time in the hospital. So Satellite Healthcare, a not-for-profit chain that uses its Wellbound subsidiary to help promote home therapies to those who are interested, has 22% of its patients on home therapies. Northwest Kidney has about 17% of patients dialyzing at home. That means fewer hospital admissions.. That's a lesson for any provider.

At this stage of the game, quality improvement is at the top of every dialysis company’s agenda: it saves money, keeps patients healthier, and directs resources to more deserved benefits. For profits can learn from not-for-profits, but let’s not discount DaVita’s Cathaway program to reduce catheter use, and Fresenius Medical Care’s Right Return program to reduce hospital readmissions of dialysis patients. The goals are the same for all.