Study: Hemodialysis patients treated in for-profit centers have higher hospitalization rate

UPDATE: An earlier version of this article stated in the headline that hemodialysis patients treated in for-profit centers have higher mortality rates. The study actually only shows higher rates of hospitalization, not mortality.

Patients receiving hemodialysis in for-profit facilities had a 15% higher relative rate of hospitalization compared with those in nonprofit facilities, a study published online Dec. 26 in the Clinical Journal of the American Society of Nephrology found.

Researchers conducted a retrospective cohort study using the U.S. Renal Data System, including all adults aged 18–100 years old who started dialysis between Jan. 1, 2005 and June 30, 2008. Patients who died, received a kidney transplant, recovered kidney function, or were lost to follow-up in the first 90 days of dialysis were excluded. The cohort included 150,642 dialysis patients, of which 12,985 (9%) were receiving care in nonprofit dialysis facilities. In adjusted models, the study authors said they found patients receiving hemodialysis in for-profit facilities had a 15% higher relative rate of hospitalization compared with those in nonprofit dialysis facilities. Patients on hemodialysis receiving care in for-profit dialysis facilities had a 37% higher rate of hospitalization for heart failure or volume overload and a 15% higher rate of hospitalization for vascular access complications. Among patients receiving peritoneal dialysis, the rate of hospitalization in for-profit versus nonprofit facilities was not significantly different, according to the study.

(CMS takes a step back on tackling hospitalizations under the ESRD QIP)

"Proposed mechanisms by which profit status and organizational structure may be linked to adverse outcomes include differences in staffing, training level of staff, and specific differences in treatment or processes of care such as hemodialysis session length and medication dosing protocols," the authors wrote.

Baseline characteristics for adults on hemodialysis differed among those in for-profit compared with nonprofit dialysis facilities. The proportion of patients with hemodialysis catheters at the start of dialysis was higher in for-profit facilities. The prevalence of atherosclerotic heart disease, cerebrovascular accident or transient ischemic attack, cancer, pulmonary disease, and inability to ambulate or transfer was significantly higher in nonprofit facilities, the authors wrote. The proportion of patients with reported nephrology care before ESRD was higher in nonprofit facilities, and the distribution of patients by profit status differed by region. In adults on peritoneal dialysis, the prevalence of baseline chronic diseases was similar among patients in for-profit and nonprofit dialysis facilities.

"Amid the concerns about whether ESRD patient outcomes are affected by the profit status of dialysis providers, it is important to stress that not all for-profit providers are equal, and even if there is some relationship between outcomes and profit status, that characterization may not apply to all for-profit (or nonprofit, for that matter) organizations," Barry M. Straube, MD, said in an accompanying editorial.

(The CMO Initiative: Improving vascular access outcomes in dialysis patients)

"Dialysis organizations vary significantly not only in size, geographic locations, patient demographics, nephrologists, management styles, and so forth; but there are also different ownership and governance structures across for-profits, which make generalized characterizations quite difficult … If for-profit status matters regarding health outcomes, population studies are heavily skewed by one or both of the large for-profit dialysis organizations. The key need for health policy makers is information down to the corporate (or preferably the individual facility) level, not broad category results reported in studies to date. Any dialysis organization will likely have variable results across its individual facilities and this may have nothing to do with profit status."

The study, "Comparison of Hospitalization Rates among For-Profit and Nonprofit Dialysis Facilities," is available online.

Study authors include, Lorien S. Dalrymple, Kirsten L. Johansen, Patrick S. Romano, Glenn M. Chertow, Yi Mu, Julie H. Ishida, Barbara Grimes, George A. Kaysen, Danh V. Nguyen.