Abstract
BackgroundPatient outcomes have been compared on the basis of the profit status of the dialysis provider (for-profit [FP] and not-for-profit [NFP]). In its annual report, United States Renal Data System (USRDS) provides dialysis provider level death and hospitalization rates adjusted by age, race, sex, and dialysis vintage; however, recent analyses have suggested that other variables impact these outcomes. Our current analysis of hospitalization and mortality rates of hemodialysis patients included adjustments for those used by the USRDS plus other potential confounders: facility geography (end-stage renal disease network), length of facility ownership, vascular access at first dialysis session, and pre-dialysis nephrology care.MethodsWe performed a provider level, retrospective analysis of 2010 hospitalization and mortality rates among US hemodialysis patients exclusively using USRDS sources. Crude and adjusted incidence rate ratios (IRRs) were calculated using the 4 standard USRDS patient factors plus the 4 potential confounders noted above.ResultsThe analysis included 366,011 and 34,029 patients treated at FP and NFP facilities, respectively. There were statistical differences between the cohorts in geography, facility length of ownership, vascular access, and pre-dialysis nephrology care (p < 0.001), as well as age (p < 0.01), race (p < 0.001), and vintage (p < 0.001), but not sex (p = 0.12). When using standard USRDS adjustments, hospitalization and mortality rates for FP and NFP facilities were most disparate, favoring the NFP facilities. Rates were most similar between providers when adjustments were made for each of the 8 factors. With the FP IRR as the referent (1.0), the hospitalization IRR for NFP facilities was 1.00 (95% confidence interval [CI] 0.97-1.02; p = 0.69), while the NFP mortality IRR was 1.01 (95% CI 0.97-1.05; p = 0.64).ConclusionsThese data suggest there is no difference in mortality and hospitalization rates between FP and NFP dialysis clinics when appropriate statistical adjustments are made.
Highlights
Patient outcomes have been compared on the basis of the profit status of the dialysis provider
Length of ownership was significantly longer for NFP versus FP facilities
Patients treated at NFP dialysis facilities more frequently received their first dialysis treatment with an AVF (19.7%) compared to those patients in the FP population (17.0%; p < 0.001), while individuals treated at FP dialysis facilities were more frequently first dialyzed with a CVC in place (78.0%) than NFP (75.6%; p < 0.001)
Summary
Patient outcomes have been compared on the basis of the profit status of the dialysis provider (for-profit [FP] and not-for-profit [NFP]). In its annual report, United States Renal Data System (USRDS) provides dialysis provider level death and hospitalization rates adjusted by age, race, sex, and dialysis vintage; recent analyses have suggested that other variables impact these outcomes. The USRDS Annual Data Report includes a dialysis provider-level favorable distributions of these factors, it is possible that prior published comparisons of outcomes between FP and NFP facilities have biases that affect the results. With the advent of sophisticated analytical techniques, more recent provider-level analyses have attempted to account for confounding derived from differences that exist between dialysis provided at FP versus NFP facilities [15]. The purpose of our current investigation was to characterize case mix differences between FP and NFP facilities and to estimate the associations of profit status with mortality and hospitalization rates adjusted for traditional and non-traditional confounders so as to provide less biased comparisons. In order to minimize ascertainment bias, all study data were taken from USRDS Standard Analytical Files
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