Price of dialysis, unit staffing, and length of dialysis treatments

Effect of profit status in facilities on the mortality of patients on long-term haemodialysis: a nationwide cohort study

OBJECTIVES

Over the past two decades, debates on whether the profit status of dialysis facilities influences patient prognosis have been popular in the USA. Taiwan is one of the regions with the highest rate per capita of kidney replacement therapy worldwide, but no similar research has been conducted to date. This is the first study to address this issue.

DESIGN

This was a nationwide retrospective cohort study based on the Taiwan Renal Registry Data System.

SETTING

Patients were categorised into two groups based on the profit status (for-profit, not-for-profit (NFP)) of dialysis facilities, with 31 350 patients in each group. The patients were followed up from 2005 to 2012.

PARTICIPANTS

Patients with uraemia who underwent long-term haemodialysis in private dialysis facilities and public facilities were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

Survival analyses were performed to compare prognosis between the two groups. Adjustments to patients' basic profile, and facilities' geographical distribution, level, and length of ownership were carried out to minimise possible confounding effects.

RESULTS

Analysis revealed that NFP dialysis facilities had better outcomes (HR=0.91, 95% CI (0.89 to 0.93)). A favourable effect remains with the adjustment of the facilities' level, geographical distribution (HR=0.89, 95% CI (0.86 to 0.93)) or length of ownership (HR=0.95, 95% CI (0.89 to 0.95)). Survival analysis based on the geographical distribution and level of facilities was also conducted, which showed better prognosis in medical centres in the six municipalities, whereas worse prognosis was found in local hospitals not located in these municipalities.

CONCLUSION

Our findings suggest that in contemporary settings in Taiwan, treatment at NFP dialysis facilities was associated with a better prognosis. The results should be interpreted with caution since the possibility of residual confounding effects and uncertainty of casual relations exist due to the nature of observational studies.

Telemedicine in the Satellite Dialysis Unit: Is It Feasible and Safe?

Telemedicine has gained popularity during the recent COVID-19 pandemic. Regular and timely physician review is an essential component of care for the maintenance of hemodialysis patients. While it is widely acknowledged that telemedicine cannot fully replace the role of physical review in this group of patients with organ failure, it can perhaps reduce the reliance on physical review or serve as a filter and triage in determining which patient requires actual physical review. The use of technology in any healthcare setting should always align with existing clinical workflow and protocols. We discuss the safety and quality aspects of this new concept applied to the satellite dialysis unit.

Erythropoietin Treatment Decreases Cardiovascular Morbidity and Mortality in Capd Patients

Objective

To analyze the effects of recombinant human erythropoietin (rHuEPO) therapy on cardiovascular (CV) morbidity and mortality among continuous ambulatory peritoneal dialysis (CAPD) patients.

Design

Retrospective comparative study.

Setting

CAPD unit in a university hospital.

Patients

Forty-two patients on rHuEPO treatment for at least one year were compared with an rHuEPO nonuser group of 113 patients. Subcutaneous rHuEPO doses were adjusted to a hemoglobin objective level of 10.5 -13.5 g/ dL. Fifty-seven patients were considered as high cardiovascular risk (HCVR), 17 in the rHuEPO group and 40 in the rHuEPO nonuser group. Ninety-eight patients were classified as low cardiovascular risk (LCVR), 25 of whom were in the rHuEPO group.

Results

The incidence of cardiovascular morbidity was more frequent in the rHuEPO nonuser than in the rHuEPO user group (40% vs 22%) and in HCVR than in LCVR patients (59.6% vs 20.4%). By multiple logistic regression analysis, the best model to explain the development of cardiovascular morbidity comprises rHuEPO treatment, CV risk, and age. In the rHuEPO user group, HCVR and LCVR patients did not show significant differences in survival, while in the rHuEPO nonuser group, HCVR patients had a lower survival rate than LCVR patients (p = 0.0003). Cox proportional hazards model revealed that LCVR patients had an excellent prognosis compared with HCVR patients in the rHuEPO nonuser group, but this difference disappeared in the rHuEPO user group.

Conclusion

These data show a beneficial effect of rHuEPO treatment on cardiovascular morbidity and mortality in CAPD patients, evidenced by the elimination of the correlation between prior cardiovascular risk and subsequent mortality.

Association Between Dialysis Facility Ownership and Access to Kidney Transplantation

IMPORTANCE

For-profit (vs nonprofit) dialysis facilities have historically had lower kidney transplantation rates, but it is unknown if the pattern holds for living donor and deceased donor kidney transplantation, varies by facility ownership, or has persisted over time in a nationally representative population.

OBJECTIVE

To determine the association between dialysis facility ownership and placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study that included 1 478 564 patients treated at 6511 US dialysis facilities. Adult patients with incident end-stage kidney disease from the US Renal Data System (2000-2016) were linked with facility ownership (Dialysis Facility Compare) and characteristics (Dialysis Facility Report).

EXPOSURES

The primary exposure was dialysis facility ownership, which was categorized as nonprofit small chains, nonprofit independent facilities, for-profit large chains (>1000 facilities), for-profit small chains (<1000 facilities), and for-profit independent facilities.

MAIN OUTCOMES AND MEASURES

Access to kidney transplantation was defined as time from initiation of dialysis to placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant. Cumulative incidence differences and multivariable Cox models assessed the association between dialysis facility ownership and each outcome.

RESULTS

Among 1 478 564 patients, the median age was 66 years (interquartile range, 55-76 years), with 55.3% male, and 28.1% non-Hispanic black patients. Eighty-seven percent of patients received care at a for-profit dialysis facility. A total of 109 030 patients (7.4%) received care at 435 nonprofit small chain facilities; 78 287 (5.3%) at 324 nonprofit independent facilities; 483 988 (32.7%) at 2239 facilities of large for-profit chain 1; 482 689 (32.6%) at 2082 facilities of large for-profit chain 2; 225 890 (15.3%) at 997 for-profit small chain facilities; and 98 680 (6.7%) at 434 for-profit independent facilities. During the study period, 121 680 patients (8.2%) were placed on the deceased donor waiting list, 23 762 (1.6%) received a living donor kidney transplant, and 49 290 (3.3%) received a deceased donor kidney transplant. For-profit facilities had lower 5-year cumulative incidence differences for each outcome vs nonprofit facilities (deceased donor waiting list: -13.2% [95% CI, -13.4% to -13.0%]; receipt of a living donor kidney transplant: -2.3% [95% CI, -2.4% to -2.3%]; and receipt of a deceased donor kidney transplant: -4.3% [95% CI, -4.4% to -4.2%]). Adjusted Cox analyses showed lower relative rates for each outcome among patients treated at all for-profit vs all nonprofit dialysis facilities: deceased donor waiting list (hazard ratio [HR], 0.36 [95% CI, 0.35 to 0.36]); receipt of a living donor kidney transplant (HR, 0.52 [95% CI, 0.51 to 0.54]); and receipt of a deceased donor kidney transplant (HR, 0.44 [95% CI, 0.44 to 0.45]).

CONCLUSIONS AND RELEVANCE

Among US patients with end-stage kidney disease, receiving dialysis at for-profit facilities compared with nonprofit facilities was associated with a lower likelihood of accessing kidney transplantation. Further research is needed to understand the mechanisms behind this association.

The Role of Big Data in the Development and Evaluation of US Dialysis Care

Rapid growth in electronic communications and digitalization, combined with advances in data management, analysis, and storage, have led to an era of "Big Data." The Social Security Amendments of 1972 turned end-stage renal disease (ESRD) care into a single-payer system for most patients requiring dialysis in the United States. As a result, there are few areas of medicine that have been as influenced by Big Data as dialysis care, for which Medicare's large administrative data sets have had a central role in the evaluation and development of public policy for several decades. In the 1970/1980s, Medicare data helped identify concerning trends in costs, access to dialysis care, and quality of care delivered. As the research community and policymakers made Medicare's administrative data increasingly accessible for investigation, analyses of Medicare claims have had a large role in facilitating policy synthesis and refinement. Efforts to address the skyrocketing cost of injectable drugs in the 1990s and 2000s exemplify this expanded role of Big Data. Although there are opportunities for large government and nongovernmental administrative data sets to continue serving a critical role in the evaluation and development of ESRD policies, it is important to understand challenges and limitations associated with their use.

Impact of the End Stage Renal Disease Prospective Payment System on the Use of Peritoneal Dialysis

Introduction

The End Stage Renal Disease (ESRD) Prospective Payment System (PPS), implemented by the Centers for Medicare and Medicaid Services in January 2011, encouraged use of peritoneal dialysis (PD) through various financial incentives. Our goal was to determine whether PPS effectively increased PD use in incident dialysis patients.

Methods

Our study used the United States Renal Data System (USRDS) to identify 430,927 adult patients who initiated dialysis between 2009 and 2012. The interrupted time series method was used to evaluate the association Centers for Medicare and Medicaid Services of PPS with PD use at dialysis initiation. We further stratified by patient demographics, predialysis care, and facility chain and profit status.

Results

Interrupted time series analysis indicated PPS was associated with increased PD use in the 2-year period after PPS (change in slope = 0.04, P < 0.0001), although there was no immediate change in the level of PD use at the beginning of PPS (P = 0.512). Stratified analyses indicated PPS led to increased PD use across all age, race, and sex groups (P < 0.05) although marginally among females (P = 0.09). Notably, small dialysis organizations and nonprofit organizations appeared to increase use of PD faster compared to large dialysis organizations and for-profit units, respectively.

Discussion

Implementation of the Centers for Medicare and Medicaid Services ESRD payment reform was associated with an increased use of PD in the 2 years after PPS. Our findings highlight the role of financial incentives in changing practice patterns to increase use of a dialysis modality considered to be both more cost-effective and empowering to ESRD patients. However, even after PPS, rates of PD use remain low among the dialysis population in the USA.

Hemodialysis system privatization and patient survival: a report from a large registry Eastern Europe cohort

BACKGROUND

There has been a rapid increase in incident and prevalent rates of hemodialysis (HD) patients in Romania following the 2004 system privatization, but little is known about the impact of privatization on patient outcomes.

METHODS

We retrospectively examined the outcome during 1 year of 8161 prevalent HD patients registered in the Romanian Renal Registry at 31 December 2011. Standardized mortality ratio (SMR) was calculated for each for-profit (FP) and non-profit (NP) HD provider.

RESULTS

The 12-month SMR across all HD chain providers was 1.27. FP Chain 1 and the "other" group had SMR similar to the reference level. The mortality rate was two times higher in public NP dialysis centers than the national reference. A stepwise Cox regression analysis identified older age, male gender, DN as primary renal disease and the HD chain provider to be independently associated with a higher mortality. Excepting patients treated by FP Chain 4, patients treated by all the other dialysis providers had a better outcome than those treated in NP facilities.

CONCLUSION

In conclusion, the increase in number of patients treated was not doubled by an increase in their survival. In the context of an expanding dialysis marketplace that tends to consolidate around large for-profit (FP) providers, further exploration of indicators associated with mortality may guide future healthcare policy to improve patient outcomes.

Longer dialysis session length is associated with better intermediate outcomes and survival among patients on in-center three times per week hemodialysis: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS)

BACKGROUND

Longer dialysis session length (treatment time, TT) has been associated with better survival among hemodialysis (HD) patients. The impact of TT on clinical markers that may contribute to this survival advantage is not well known.

METHODS

Using data from the international Dialysis Outcomes and Practice Patterns Study, we assessed the association of TT with clinical outcomes using both standard regression analyses and instrumental variable approaches. The study included 37,414 patients on in-center HD three times per week with prescribed TT from 120 to 420 min.

RESULTS

Facility mean TT ranged from 214 min in the USA to 256 min in Australia-New Zealand. Accounting for country effects, mortality risk was lower for patients with longer TT {hazard ratio for every 30 min: all-cause mortality: 0.94 [95% confidence interval (CI): 0.92-0.97], cardiovascular mortality: 0.95 (95% CI: 0.91-0.98) and sudden death: 0.93 (95% CI: 0.88-0.98)}. Patients with longer TT had lower pre- and post-dialysis systolic blood pressure, greater intradialytic weight loss, higher hemoglobin (for the same erythropoietin dose), serum albumin and potassium and lower serum phosphorus and white blood cell counts. Similar associations were found using the instrumental variable approach, although the positive associations of TT with weight loss and potassium were lost.

CONCLUSIONS

Favorable levels of a variety of clinical markers may contribute to the better survival of patients receiving longer TT. These findings support longer TT prescription in the setting of in-center, three times per week HD.

The effect of dialysis chains on mortality among patients receiving hemodialysis

OBJECTIVE

To examine the association between dialysis facility chain affiliation and patient mortality.

STUDY SETTING

Medicare dialysis population.

STUDY DESIGN

Data from the United States Renal Data System (USRDS) were used to identify 3,601 free-standing dialysis facilities and 34,914 Medicare patients' incidence to end-stage renal disease (ESRD) in 2004. Mixed-effect regression models were used to estimate patient mortality by dialysis facility chain and profit status during the 2-year follow-up.

DATA COLLECTION

USRDS data were matched with facility, cost, and census data.

PRINCIPAL FINDINGS

Of the five largest dialysis chains, the lowest mortality risk was observed among patients dialyzed at nonprofit (NP) Chain 5 facilities. Compared with Chain 5, hazard ratios were 19 percent higher (95 percent CI 1.06-1.34) and 24 percent higher (95 percent CI 1.10-1.40) for patients dialyzed at for-profit (FP) Chain 1 and Chain 2 facilities, respectively. In addition, patients at FP facilities had a 13 percent higher risk of mortality than those in NP facilities (95 percent CI 1.06-1.22).

CONCLUSIONS

Large chain affiliation is an independent risk factor for ESRD mortality in the United States. Given the movement toward further consolidation of large FP chains, reasons behind the increase in mortality require scrutiny.

Effect of dialysis center profit-status on patient survival: a comparison of risk-adjustment and instrumental variable approaches

OBJECTIVE

To compare the estimated effects of dialysis center profit status on patient survival using alternative estimation strategies with retrospective data.

DATA SOURCES/STUDY SETTING

Patient and provider-level retrospective data from the United States Renal Data System (USRDS), 1996-1999.

STUDY DESIGN

Observational risk adjustment and instrumental variable methods.

DATA COLLECTION/EXTRACTION METHODS

Study collected measures from various USRDS files describing clinical characteristics, survival, and the profit status of the initial dialysis center for incident end-stage renal disease (ESRD) patients aged 67+. USRDS facility files were used to assess dialysis center profit status and measure patient distances to dialysis centers.

PRINCIPAL FINDINGS

Found survival effect related to profit status in the range of previous research using risk-adjusting covariates similar to those used in previous models. Adding further risk-adjusting covariates halved this effect. The relative proximity of for-profit and nonprofit dialysis centers to the patient residence was the strongest determinant of the profit status of the patient's initial dialysis center. The effect of profit status on survival was eliminated using the two-stage least squares variant of instrumental variable estimation with the relative proximity of for-profit and nonprofit dialysis centers to the patient's residence as the instrument.

CONCLUSIONS

Using only the variation in initial dialysis center profit status that was related to the relative proximity of for-profit and nonprofit dialysis centers to the patient, we found no relationship between dialysis center profit status and patient survival. These results are in contrast to results obtained using risk-adjustment methods with a limited set of risk-adjusting covariates.

Associations between CMS's Clinical Performance Measures project benchmarks, profit structure, and mortality in dialysis units

Prior studies observing greater mortality in for-profit dialysis units have not captured information about benchmarks of care. This study was undertaken to examine the association between profit status and mortality while achieving benchmarks. Utilizing data from the US Renal Data System and the Centers for Medicare & Medicaid Services' end-stage renal disease (ESRD) Clinical Performance Measures project, hemodialysis units were categorized as for-profit or not-for-profit. Associations with mortality at 1 year were estimated using Cox regression. Two thousand six hundred and eighty-five dialysis units (31,515 patients) were designated as for-profit and 1018 (15,085 patients) as not-for-profit. Patients in for-profit facilities were more likely to be older, black, female, diabetic, and have higher urea reduction ratio (URR), hematocrit, serum albumin, and transferrin saturation. Patients (19.4 and 18.6%) in for-profit and not-for-profit units died, respectively. In unadjusted analyses, profit status was not associated with mortality (hazard ratio (HR)=1.04, P=0.09). When added to models with profit status, the following resulted in a significant association between profit status (for-profit vs not-for-profit) and increasing mortality risk: URR, hematocrit, albumin, and ESRD Network. In adjusted models, patients in for-profit facilities had a greater death risk (HR 1.09, P=0.004). More patients in for-profit units met clinical benchmarks. Survival among patients in for-profit units was similar to not-for-profit units. This suggests that in the contemporary era, interventions in for-profit dialysis units have not impaired their ability to deliver performance benchmarks and do not affect survival.

Factors Influencing Route of Administration for Epoetin Treatment Among Hemodialysis Patients in the United States

BACKGROUND

Published clinical guidelines advocate subcutaneous (SC) administration for epoetin therapy, although this is practiced among only 7% of all hemodialysis patients. Despite this disparity, few studies have examined factors associated with route of epoetin administration in hemodialysis patients.

METHODS

Data from the Centers for Medicare & Medicaid Services End-Stage Renal Disease Clinical Performance Measures Project were used to identify 13,854 patients receiving hemodialysis in 3,069 dialysis facilities from October to December in 1999 and 2000. Unadjusted associations were examined by using t-test and chi-square test. Adjusted associations were estimated by using generalized estimating equations to control for clustering of patients within the same dialysis facility.

RESULTS

In the United States, use of the SC route of epoetin administration varies widely across the country. After adjusting for patient sociodemographics and comorbidities, the greatest rates of SC therapy are found in the Midwest and West, in providers not affiliated with chains, and in hospital-based and not-for-profit freestanding units. Previous exposure to SC administration (as a predialysis or peritoneal dialysis patient) predicted subsequent SC use, for-profit and large chains were significantly less likely to use SC administration, and increased use of injectable drugs overall (to maximize income) was associated with less SC use.

CONCLUSION

In addition to regional variation in SC use, study findings indicate that physician decision making for epoetin administration route is influenced primarily by type of ownership and financial incentives. Adherence to published clinical guidelines was not a consistent predictor of SC use. Given the similar effectiveness, but significantly decreased dose associated with SC epoetin, these findings suggest an enormous opportunity for cost savings for the Medicare program.

Dialysis session length ("t") as a determinant of the adequacy of dialysis

Several studies have shown an association between the hemodialysis session length (the t of Kt or Kt/V) and favorable outcomes for patients on maintenance hemodialysis. In a single randomized controlled trial that systematically varied hemodialysis session length, shorter session length was associated with an increased risk for morbidity and mortality, independent of the time-averaged concentration of urea. Observational studies of dialysis session length have yielded conflicting results, although virtually all studies have confounded hemodialysis session length with hemodialysis efficiency or dose. Limited observational data from nocturnal hemodialysis programs more strongly suggest an independent beneficial effect of longer session length. In aggregate, data on the effects of hemodialysis session length are inconclusive. Future studies should evaluate hemodialysis session length independent of efficiency, and should consider the evaluation of dose by using other clearance parameters and the adequacy of ultrafiltration in addition to solute kinetics.

Longitudinal Analysis of Efficiency in Multiple Output Dialysis Markets

Provider efficiency in the dialysis industry in the U.S.A. has been of great interest for a variety of parties mainly because of the continuing growth in the number of such patients and providers and in the industry's costs. This study examined technical efficiency longitudinally among the multiple-output producers of freestanding facilities, as the dominant group of providers, using the DEA-based Malmquist index. Nationally representative data were obtained from Independent Renal Facility Cost Report Data Files for the years 1994 through 2000. The resulting sample comprised 140 facilities that had operated throughout the seven study years and jointly produced all dialysis outputs with nonzero inputs. The results show that over the period 1994-2000, on average multi-output, freestanding dialysis facilities did not achieve improvement in productivity. Decomposition of the Malmquist productivity indices showed improvement in technical efficiency but at the same time regress in technologies with potential to improve their quality of care. Negative change in technology was the major source of negative movement in productivity. The study concludes that under the fixed-price payment policy, multiple dialysis outputs are produced efficiently, but it may be that the quality of care is being sacrificed.

Survival by time of day of hemodialysis: analysis of United States Renal Data System Dialysis Morbidity and Mortality Waves III/IV

BACKGROUND

Whether morning shift hemodialysis is associated with improved survival in comparison to patients receiving afternoon shift hemodialysis has not been shown for a representative sample of US chronic hemodialysis patients.

METHODS

We conducted a historical cohort study of a national database (US Renal Data System Dialysis Morbidity and Mortality Waves III/IV) of 6,939 patients who started hemodialysis therapy from January 1, 1990, through December 31, 1993. Patients were followed up through April 9, 2000, and censored at the time of change to a different modality, including transplantation. We estimated the adjusted hazard ratio for all-cause mortality based on the time of day of hemodialysis (0500 to 1200 for morning shift, 1200 to 1800 for afternoon shift, 1800 to midnight for evening shift). Cox regression analysis was used to adjust for other factors associated with survival.

RESULTS

For patients aged 60 years and older, the unadjusted 4-year survival rate for patients on morning shift hemodialysis was 28.8% versus 24.1% for patients on afternoon shift hemodialysis and 38.7% for patients on evening shift hemodialysis (P < 0.01 by log-rank test for both versus afternoon shift hemodialysis). Both morning shift (adjusted hazard ratio, 0.90; 95% confidence interval [CI], 0.83 to 0.98; P = 0.02) and evening shift hemodialysis (adjusted hazard ratio, 0.62; 95% CI, 0.48 to 0.80; P < or = 0.001) were independently associated with a lower risk for mortality compared with afternoon shift hemodialysis. No such differences were seen for patients younger than 60 years. Both morning shift and evening shift hemodialysis were independently associated with improved survival compared with afternoon shift hemodialysis in elderly chronic hemodialysis patients. No such association was found for younger patients.

A national study of efficiency for dialysis centers: an examination of market competition and facility characteristics for production of multiple dialysis outputs

OBJECTIVE

To examine market competition and facility characteristics that can be related to technical efficiency in the production of multiple dialysis outputs from the perspective of the industrial organization model.

STUDY SETTING

Freestanding dialysis facilities that operated in 1997 submitted cost report fonns to the Health Care Financing Administration (HCFA), and offered all three outputs--outpatient dialysis, dialysis training, and home program dialysis.

DATA SOURCES

The Independent Renal Facility Cost Report Data file (IRFCRD) from HCFA was utilized to obtain information on output and input variables and market and facility features for 791 multiple-output facilities. Information regarding population characteristics was obtained from the Area Resources File.

STUDY DESIGN

Cross-sectional data for the year 1997 were utilized to obtain facility-specific technical efficiency scores estimated through Data Envelopment Analysis (DEA). A binary variable of efficiency status was then regressed against its market and facility characteristics and control factors in a multivariate logistic regression analysis.

PRINCIPAL FINDINGS

The majority of the facilities in the sample are functioning technically inefficiently. Neither the intensity of market competition nor a policy of dialyzer reuse has a significant effect on the facilities' efficiency. Technical efficiency is significantly associated, however, with type of ownership, with the interaction between the market concentration of for-profits and ownership type, and with affiliations with chains of different sizes. Nonprofit and government-owned Facilities are more likely than their for-profit counterparts to become inefficient producers of renal dialysis outputs. On the other hand, that relationship between ownership form and efficiency is reversed as the market concentration of for-profits in a given market increases. Facilities that are members of large chains are more likely to be technically inefficient.

CONCLUSIONS

Facilities do not appear to benefit from joint production of a variety of dialysis outputs, which may explain the ongoing tendency toward single-output production. Ownership form does make a positive difference in production efficiency, but only in local markets where competition exists between nonprofit and for-profit facilities. The increasing inefficiency associated with membership in large chains suggests that the growing consolidation in the dialysis industry may not, in fact, be the strategy for attaining more technical efficiency in the production of multiple dialysis outputs.

Quality of care differences by ownership in United States renal dialysis facilities

Recent studies of patient outcomes in the United States have shown mixed conclusions regarding the effect of for-profit ownership on treatment quality. To test whether outcome quality differs across ownership types for patients being treated for end stage renal disease, a cross-sectional study was performed using data from 180,913 end stage renal disease patients receiving center based hemodialysis in 1996. Results indicated that patients in for-profit renal dialysis facilities had slightly higher mortality during the study period than patients in not-for-profit facilities, after controlling for patient case mix and market type. For profit ownership seems to affect not only treatment inputs, according to previous research, but also patient outcomes, as indicated by the results here.

Effect of the ownership of dialysis facilities on patients' survival and referral for transplantation

BACKGROUND

More than 200,000 patients with end-stage renal disease undergo dialysis in the United States each year, about two thirds in for-profit centers. Economic pressures, such as the decline in inflation-adjusted Medicare payments for dialysis, may compromise the quality of care. Facilities may also be reluctant to refer patients to be evaluated for transplantation because of the loss of revenues from dialysis after patients receive transplants. It is unknown whether for-profit facilities respond more aggressively than not-for-profit facilities to these financial pressures. Therefore, we examined the effect of for-profit ownership of dialysis facilities on patients' survival and referral for possible transplantation.

METHODS

We used data from the U.S. Renal Data System to assemble a nationally representative cohort of patients with end-stage renal disease of recent onset. We followed patients for a minimum of three years and a maximum of six years, until death, placement on the waiting list for a renal transplant, or loss to follow-up, or until May 31, 1996. We used proportional-hazards models to assess the effect of the profit status of the dialysis facility on patients' outcomes and adjusted for differences in sociodemographic, clinical, and facility-level characteristics.

RESULTS

Of the 3681 patients who were eligible for inclusion, we included 3569 in the analysis of mortality and 3441 in the analysis of the waiting list. The crude mortality rate per 100 person-years of end-stage renal disease was 21.2 for patients treated in for-profit facilities and 17.1 for patients treated in not-for-profit centers (adjusted relative hazard, 1.20; 95 percent confidence interval, 1.02 to 1.42). The likelihood of being placed on the waiting list for a renal transplant was lower for patients treated at for-profit centers (adjusted relative hazard, 0.74; 95 percent confidence interval, 0.56 to 0.98).

CONCLUSIONS

In the United States, for-profit ownership of dialysis facilities, as compared with not-for-profit ownership, is associated with increased mortality and decreased rates of placement on the waiting list for a renal transplant.

In search of ideal hemodialysis: is prolonged frequent dialysis the answer?

Advances in technology have made it possible to deliver a high Kt/V in a shorter time. The realization that duration of dialysis may be an important predictor of survival independent of dialysis dose has resulted in the popularity of prolonged slow dialysis (PHD). The longer duration and increased frequency of dialysis achieve excellent small- and middle-molecular weight solute clearance and also attenuate the peak concentration of uremic toxins. The slow dialysis process enables the equilibration of tissue and vascular compartments, resulting in better clearance and decreased postdialysis rebound increase in solutes. Gentle, persistent ultrafiltration allows the control of hypertension with minimal antihypertensive use. The intense and more frequent dialysis improves appetite and permits liberalization of diet. This greater dietary protein intake results in a progressive increase in serum albumin level and dry weight. Nocturnal hemodialysis achieves control of hyperphosphatemia without phosphate binders and a significant reduction in serum beta(2)-microglobulin levels. Normalization of extracellular volume, better clearance of uremic toxins, and improved nutrition result in a significant improvement in survival. The flexible time schedule with home hemodialysis and improvement of sleep and neurocognitive function allow better rehabilitation. The available evidence indicates PHD may be closer to the concept of an ideal dialysis, but there is lingering uncertainty about the consequence of prolonged immune stimulation, catabolism, and loss of essential solutes with these therapies.

Psychosocial adjustment of males on three types of dialysis

End-stage renal disease (ESRD) is a chronic illness that challenges the coping ability of patients and their families, demanding behavioral and emotional lifestyle changes. The purposes of this comparative descriptive study were to explore the anxiety, depression, and psychosocial adjustment of male patients on three types of dialysis--home hemodialysis (home HD), in-center hemodialysis (in-center HD), and peritoneal dialysis (PD)--and to identify perception of hemodialysis stressors for those on home HD and in-center HD. Five subjects in each of the three groups (N = 15), matched for age, gender, education, and dialysis type, participated in the study. Although the convenience sample size is too small to generalize, subjects on home HD demonstrated higher psychosocial adjustment. The study supports further research with larger, randomized samples. Information about psychosocial adjustment of patients on each type of dialysis provides information for nurses as they guide patients in choosing dialysis type.

Competition under fixed prices: effects on patient selection and service strategies by hemodialysis providers

Dialysis services for patients with end-stage renal disease (ESRD) are delivered by predominantly private providers competing in local markets. Because prices are fixed by Medicare, providers can only compete on product quality. Using 1990 data and multiple competition measures, this study examines how competition under fixed prices influences hemodialysis providers' strategies for patient selection and service levels. It finds that provider strategies vary with competition, but competitive effects are not dominant and they differ by provider type. Providers with greater competition accept more costly patients, suggesting that competition may be contributing to changes in the Medicare ESRD population to an older and sicker patient mix. Only hospital-based facilities use richer staffing in more competitive markets. For-profit, free-standing facilities in all markets have lean staffing. Rural facilities have higher staff productivity than facilities in concentrated urban markets.

Hemodialysis therapy in the United States: what is the dose and does it matter?

There is an ongoing discussion in the renal community about how to monitor the treatment of hemodialysis patients in the United States. Comparison of the US patient experience to that of other countries with populations of similar health status is one way to assess treatment. Another technique involves examining the level of dialysis therapy US patients receive. This paper reviews recent studies which found that the United States has higher mortality than both Japan and Europe and provides additional information as to why those comparisons might be underestimating the mortality differences. We also examine the data on the level of dialysis US patients receive, both as a prescription and as delivered care. We conclude that US patients receive less hemodialysis therapy than their European and Japanese counterparts, and that in general US patients are not receiving the level of dialysis they were prescribed. These factors are correlated with an increased mortality among US hemodialysis patients.

Measuring, managing, and improving quality in the end-stage renal disease treatment setting: peritoneal dialysis

Peritoneal dialysis is now performed as an end-stage renal disease modality in nearly 70,000 patients worldwide. The use of this modality varies widely from less than 5% of all end-stage renal disease patients in Japan to over 95% of patients in Mexico. In addition to medical and psychosocial factors, modality selection involves many other factors, including financial reimbursement, educational deficiencies, resource availability, social mores, and cultural habits. Survival on chronic peritoneal dialysis is similar to that on hemodialysis, although older diabetic patients on peritoneal dialysis may have a higher mortality rate. Hospitalizations and transfer off modality are more common in patients on chronic peritoneal dialysis compared with patients on hemodialysis. The important factors contributing to outcome in patients on chronic peritoneal dialysis are unknown. Results of the Baxter Best-Demonstrated Practice Program suggest that process of care has a strong impact on outcome, at least in retention of patients on chronic peritoneal dialysis. Quality of life is another outcome that has been poorly assessed in chronic peritoneal dialysis patients. Available studies suffer from a lack of standardization of instruments used, no control groups, no random patient allocation to modalities, and short-term, small population groups. When chronic peritoneal dialysis and hemodialysis are compared, subjective quality of life is generally higher with chronic peritoneal dialysis. For objective quality of life, the balance of studies favor hemodialysis. It is clear that there is a dearth of information available on many aspects of delivery of chronic peritoneal dialysis. Future research should target patient factors that are important in morbidity and mortality with chronic peritoneal dialysis, facility factors ("process of care") that are important in morbidity and mortality with chronic peritoneal dialysis, quality of life in chronic peritoneal dialysis patients, and how to measure quality of life accurately and serially. If these issues can be addressed, algorithms could be developed to help the physician to match the end-stage renal disease patient to the treatment modality that will provide the highest quality of life, the least morbidity, and the longest survival.

Analysis of the association of dialyzer reuse practices and patient outcomes

This historic prospective study assessed the relationship between dialyzer reuse practices and hemodialysis patient mortality through 1 year of follow-up. Medicare patient demographic and survival data were combined with dialyzer reuse data from the Centers for Disease Control and Prevention's annual survey of dialysis-related diseases. Data were analyzed for the US Medicare hemodialysis population of never transplanted patients prevalent on January 1, 1989, and January 1, 1990, who were treated in freestanding dialysis units that used primarily conventional (not high-flux) dialyzers. Time to mortality, or transplant, and other censoring on December 31st of each year was regressed with proportional hazards models on patient, dialysis unit, and reuse measures. Age-, race-, and diagnosis-standardized mortality ratios for dialysis units were also regressed with weighted least squares techniques against dialysis unit and reuse measures. The results showed that patients treated in dialysis units that disinfected dialyzers with a peracetic acid, hydrogen peroxide, acetic acid mixture, or glutaraldehyde experienced higher mortality than patients treated in units that used formalin or in units that did not reuse dialyzers. The relative risk of mortality, compared with patients treated in nonreuse dialysis units, was 1.17 (P = 0.010) for glutaraldehyde and 1.13 (P < 0.001) for the peracetic acid mixture. The relative risk for formalin compared with the reference group of nonreuse was 1.06 (P = 0.088). With adjustment for several patient and dialysis unit characteristics, dialyzer reuse with certain germicides was associated with a significantly elevated mortality risk. This elevated risk, the etiology of which is currently not known, may represent a large number of potentially avoidable deaths per year. Only a large, nationally based analysis of this type has sufficient sample size to detect mortality risks such as these.

Survival analysis of dialysis patients in Okinawa, Japan (1971-1990)

We analyzed longitudinal data obtained from the initiation of chronic dialysis in Okinawa, Japan. A total of 1,982 patients (824 females and 1,158 males) were registered in the Okinawa Dialysis Study (OKIDS) up to the end of 1990. The number of patients dying, undergoing renal transplantation, or being transferred was 605 (30.5%), 75 (3.8%), and 23 (1.2%), respectively. The mean acceptance rate per million population increased from 19.7 in 1971 to 1975 to 157.4 in 1986 to 1990. The percentage of diabetic patients and the annual gross mortality rate were, respectively 0% and 0.52 (1971 to 1975), 7.3% and 0.12 (1976 to 1980), 14.4% and 0.06 (1981 to 1985), and 24.6% and 0.07 (1986 to 1990). Cox proportional hazard analysis was used to determine the relative risk (RR) for sex, primary renal disease, age at entry, and the year of starting dialysis. The RR for males was 1.09 (1.00 for females) and the 95% confidence interval (CI) was 0.93 to 1.28. The RR for diabetics was 1.88 (95% CI; 1.55 to 2.28) when that for nondiabetics was set at 1.00. The RR (95% CI) for starting dialysis in 1976 to 1980, 1981 to 1985, and 1986 to 1990 was 0.65 (0.59 to 0.72), 0.43 (0.35 to 0.52), and 0.28 (0.20 to 0.38), respectively, when the RR in 1971 to 1975 was taken as 1.00. During the last two decades, the survival of chronic dialysis patients in Okinawa has continued to improve despite the large increase in acceptance rate, the older age of the new patients, and the increase in diabetic patients.(ABSTRACT TRUNCATED AT 250 WORDS)