Quality of Care in Profit vs Not-For-Profit Dialysis CentersQuality of Care in Profit vs Not-For-Profit Dialysis Centers

JAMA. 2003;289(23):3087-3088. doi:10.1001/jama.289.23.3087

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AUTHOR INFORMATION

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

QUALITY OF CARE IN PROFIT VS NOT-FOR-PROFIT DIALYSIS CENTERS

To the Editor: In their meta-analysis, Dr Devereaux and colleagues¹ concluded that hemodialysis care in private not-for-profit centers was associated with a lower risk of mortality compared with care in private for-profit centers.

From more than 7045 citations, the authors selected only 8 to use in their analyses. Of these, 1 involved patients in a single state from 1973 to 1981²; 3 were from dissertations that have never been peer reviewed or published³^- 5; and 1 was a letter to the editor.⁶ The article by Garg et al⁷ was previously critiqued.⁸^- 9 The study of McClellan et al¹⁰ showed no differences in mortality between for-profit and not-for-profit dialysis facilities, and the study by Irvin¹¹ was an analysis of US Renal Data System (USRDS) data that found only a small (1%-2%) higher probability of dying in a for-profit dialysis unit.

The authors excluded 12 studies. Several of these analyzed USRDS data from the same time period as the studies cited by Devereaux et al, yet found smaller differences in mortality between for-profit and not-for-profit facilities. Some of the authors of the excluded studies have examined the more recent Centers for Medicare and Medicaid Services (CMS) database¹² and very recent data from the Dialysis Outcomes and Practice Patterns Study (DOPPS)¹³ and found no differences in mortality between for-profit and not-for-profit dialysis facilities.

Devereaux et al made no distinction in the type of for-profit dialysis facilities, ie, whether affiliated with a large chain, a single owner, or a small chain. A recent abstract, however, reported that major chains had superior outcomes.¹⁴

Financial Disclosure: Dr Bosch is an employee of Gambro AB, a for-profit company that provides dialysis. Dr Hakim is an employee of Renal Care Group Inc, a for-profit company that provides dialysis. Dr Lazarus is an employee of Fresenius Medical Care NA, a for-profit company that provides dialysis. Dr McAllister is an employee of DaVita Inc, a for-profit company that provides dialysis. All authors are stockholders in their respective companies.

References

Devereaux PJ, Schünemann HJ, Ravindran N. et al. Comparison of mortality between private for-profit and private not-for-profit hemodialysis centers: a systematic review and meta-analysis. JAMA.2002;288:2449-2457.

Plough AL, Salem SR, Shwartz M, Weller JM, Ferguson CW. Case mix in end-stage renal disease: differences between patients in hospital-based and freestanding treatment facilities. N Engl J Med.1984;310:1432-1436.

Farley DO. Effects of Competition on Dialysis Facility Service Levels and Patient Selection [dissertation]. Santa Monica, Calif: RAND; 1993.

Irvin RA. Ownership and mortality in the dialysis industry: multivariate regression analysis. In: Irvin RA. Quality of Care, Asymmetric Information, and Patient Outcomes in US For-Profit and Not-For-Profit Renal Dialysis Facilities [dissertation]. St Louis, Mo: Washington University; 1988:55-80.

Irvin RA. Ownership and mortality in the dialysis industry: propensity score analysis. In: Irvin RA. Quality of Care, Asymmetric Information, and Patient Outcomes in US For-Profit and Not-For-Profit Renal Dialysis Facilities [dissertation]. St. Louis, MO:Washington University; 1988:81-107.

Port FK, Wolfe RA, Held PJ. Ownership of dialysis facilities and patients' survival. N Engl J Med.2000;342:1053-1054.

Garg PP, Frick KD, Diener-West M, Powe NR. Effect of the ownership of dialysis facilities on patients' survival and referral for transplantation. N Engl J Med.1999;341:1653-1660.

Bander SJ, Lazarus JM, Lindenfeld SM. Ownership of dialysis facilities and patients' survival. N Engl J Med.2000;342:1054.

Bander SJ, Hakim R, Lazarus JM, Lindenfeld S. The for-profit providers. Nephrol News Issues.2000;14:13-15.

McClellan WM, Soucie JM, Flanders WD. Mortality in end-stage renal disease is associated with facility-to-facility differences in adequacy of hemodialysis. J Am Soc Nephrol.1998;9:1940-1947.

Irvin RA. Quality of care differences by ownership in United States renal dialysis facilities. ASAIO J.2000;46:775-778.

Wolfe RA, Ashby V, Hulbert-Shearon T, Roys E, Saran R, Port F. Mortality and transplantation rates, and practice patterns at for-profit vs non-profit and at chain vs non-chain facilities. Presented at: American Society of Nephrology 35th Annual Meeting; November 1-4, 2002; Philadelphia, Pa. Abstract SU-PO705.

McCullough KP, Held PJ, Gillespie BW, Young EW, Bragg JL, Port FK. Survival among dialysis patients in for-profit and not-for-profit hemodialysis (HD) facilities [abstract]. ASAIO J.2001;47:158.

Brier ME, Aronoff GR. Effect of the ownership of dialysis facilities on adequacy of dialysis and the treatment of anemia: comparison between for-profit and not-for-profit hemodialysis facilities from the Renal Network Data System (TRNDS). Presented at: American Society of Nephrology 35th Annual Meeting; November 1-4, 2002; Philadelphia, Pa. Abstract SU-P0723.

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