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Samaan F, Mendes Á, Carnut L. Privatization and Oligopolies of the Renal Replacement Therapy Sector on Contemporary Capitalism: A Systematic Review and the Brazilian Scenario. CLINICOECONOMICS AND OUTCOMES RESEARCH 2024; 16:417-435. [PMID: 38765895 PMCID: PMC11100955 DOI: 10.2147/ceor.s464120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/03/2024] [Indexed: 05/22/2024] Open
Abstract
Worldwide the assistance on renal replacement therapy (RRT) is carried out mainly by private for-profit services and in a market with increase in mergers and acquisitions. The aim of this study was to conduct an integrative systematic review on privatization and oligopolies in the RRT sector in the context of contemporary capitalism. The inclusion criteria were scientific articles without language restrictions and that addressed the themes of oligopoly or privatization of RRT market. Studies published before 1990 were excluded. The exploratory search for publications was carried out on February 13, 2024 on the Virtual Health Library Regional Portal (VHL). Using the step-by-step of PRISMA flowchart, 34 articles were retrieved, of which 31 addressed the RRT sector in the United States and 26 compared for-profit dialysis units or those belonging to large organizations with non-profit or public ones. The main effects of privatization and oligopolies, evaluated by the studies, were: mortality, hospitalization, use of peritoneal dialysis and registration for kidney transplantation. When considering these outcomes, 19 (73%) articles showed worse results in private units or those belonging to large organizations, six (23%) studies were in favor of privatization or oligopolies and one study was neutral (4%). In summary, most of the articles included in this systematic review showed deleterious effects of oligopolization and privatization of the RRT sector on the patients served. Possible explanations for this result could be the presence of conflicts of interest in the RRT sector and the lack of incentive to implement the chronic kidney disease care line. The predominance of articles from a single nation may suggest that few countries have transparent mechanisms to monitor the quality of care and outcomes of patients on chronic dialysis.
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Affiliation(s)
- Farid Samaan
- Planning and Evaluation Group, São Paulo State Health Department, São Paulo, SP, Brazil
- Research Division, Dante Pazzanese Cardiology Institute, São Paulo, SP, Brazil
| | - Áquilas Mendes
- Public Health School, University of São Paulo, São Paulo, SP, Brazil
- Postgraduate Program, Pontifícia Universidade Católica, São Paulo, SP, Brazil
| | - Leonardo Carnut
- Center for the Development of Higher Education in Health, Federal University of São Paulo, São Paulo, SP, Brazil
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2
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Bhatnagar A, Parvathareddy V, Winkelmayer WC, Chertow GM, Erickson KF. Market Competition and Anemia Management in the United States Following Dialysis Payment Reform. Med Care 2023; 61:787-795. [PMID: 37721983 PMCID: PMC10592119 DOI: 10.1097/mlr.0000000000001924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
BACKGROUND Whether market competition influences health care provider responses to national reimbursement reforms is unknown. OBJECTIVES We examined whether changes in anemia management after the expansion of Medicare's dialysis payment bundle varied with market competition. RESEARCH DESIGN With data from the US dialysis registry, we used a difference-in-differences (DID) design to estimate the independent associations of market competition with changes in anemia management after dialysis reimbursement reform. SUBJECTS A total of 326,150 patients underwent in-center hemodialysis in 2009 and 2012, representing periods before and after reimbursement reform. MEASURES Outcomes were erythropoiesis-stimulating agent (ESA) and intravenous iron dosage, the probability of hemoglobin <9 g/dL, hospitalizations, and mortality. We also examined serum ferritin concentration, an indicator of body iron stores. We used a dichotomous market competition index, with less competitive areas defined as effectively having <2 competing dialysis providers. RESULTS Compared with areas with more competition, patients in less competitive areas had slightly more pronounced declines in ESA dose (60% vs. 57%) following reimbursement reform (DID estimate: -3%; 95% CI, -5% to -1%) and less pronounced declines in intravenous iron dose (-14% vs. -19%; DID estimate: 5%; 95% CI, 1%-9%). The likelihoods of hemoglobin <9 g/dL, hospitalization, and mortality did not vary with market competition. Serum ferritin concentrations in 2012 were 4% (95% CI, 3%-6%) higher in less competitive areas. CONCLUSIONS After the expansion of Medicare's dialysis payment bundle, ESA use declined by more, and intravenous iron use declined by less in concentrated markets. More aggressive cost-reduction strategies may be implemented in less competitive markets.
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Affiliation(s)
| | | | | | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - Kevin F Erickson
- Baylor College of Medicine, Section of Nephrology, Houston, TX
- Baker Institute for Public Policy, Rice University, Houston, TX
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3
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Husain SA, Yu ME, King KL, Adler JT, Schold JD, Mohan S. Disparities in Kidney Transplant Waitlisting Among Young Patients Without Medical Comorbidities. JAMA Intern Med 2023; 183:1238-1246. [PMID: 37782509 PMCID: PMC10546295 DOI: 10.1001/jamainternmed.2023.5013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 08/07/2023] [Indexed: 10/03/2023]
Abstract
Importance Disparities in kidney transplant referral and waitlisting contribute to disparities in kidney disease outcomes. Whether these differences are rooted in population differences in comorbidity burden is unclear. Objective To examine whether disparities in kidney transplant waitlisting were present among a young, relatively healthy cohort of patients unlikely to have medical contraindications to kidney transplant. Design, Setting, and Participants This retrospective cohort study used the US Renal Data System Registry to identify patients with end-stage kidney disease who initiated dialysis between January 1, 2005, and December 31, 2019. Patients who were older than 40 years, received a preemptive transplant, were preemptively waitlisted, or had documented medical comorbidities other than hypertension or smoking were excluded, yielding an analytic cohort of 52 902 patients. Data were analyzed between March 1, 2022, and February 1, 2023. Main Outcome(s) and Measure(s) Kidney transplant waitlisting after dialysis initiation. Results Of 52 902 patients (mean [SD] age, 31 [5] years; 31 132 [59%] male; 3547 [7%] Asian/Pacific Islander, 20 782 [39%] Black/African American, and 28 006 [53%] White) included in the analysis, 15 840 (30%) were waitlisted for a kidney transplant within 1 year of dialysis initiation, 11 122 (21%) were waitlisted between 1 and 5 years after dialysis initiation, and 25 940 (49%) were not waitlisted by 5 years. Patients waitlisted within 1 year of dialysis initiation were more likely to be male, to be White, to be employed full time, and to have had predialysis nephrology care. There were large state-level differences in the proportion of patients waitlisted within 1 year (median, 33%; range, 15%-58%). In competing risk regression, female sex (adjusted subhazard ratio [SHR], 0.92; 95% CI, 0.90-0.94), Hispanic ethnicity (SHR, 0.77; 95% CI, 0.75-0.80), and Black race (SHR, 0.66; 95% CI, 0.64-0.68) were all associated with lower waitlisting after dialysis initiation. Unemployment (SHR, 0.47; 95% CI, 0.45-0.48) and part-time employment (SHR, 0.74; 95% CI, 0.70-0.77) were associated with lower waitlisting compared with full-time employment, and more than 1 year of predialysis nephrology care, compared with none, was associated with greater waitlisting (SHR, 1.51; 95% CI, 1.46-1.56). Conclusions and Relevance This retrospective cohort study found that fewer than one-third of patients without major medical comorbidities were waitlisted for a kidney transplant within 1 year of dialysis initiation, with sociodemographic disparities in waitlisting even in this cohort of young, relatively healthy patients unlikely to have a medical contraindication to transplantation. Transplant policy changes are needed to increase transparency and address structural barriers to waitlist access.
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Affiliation(s)
- S. Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Miko E. Yu
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Kristen L. King
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Joel T. Adler
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin
| | - Jesse D. Schold
- Department of Surgery, University of Colorado–Anschutz Medical Campus, Aurora
- Department of Epidemiology, School of Public Health, University of Colorado–Anschutz Medical Campus, Aurora
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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Erickson KF, Eck C. Considering the Effects of a Recent US Supreme Court's Ruling on Dialysis Care Costs. Clin Ther 2023; 45:272-276. [PMID: 36842865 PMCID: PMC10133009 DOI: 10.1016/j.clinthera.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/27/2023]
Abstract
Dialysis care in the United States is expensive and is mostly paid for by Medicare. To reduce the cost of providing dialysis services, the federal government has relied on a law that designates Medicare as a secondary payer in the first 30 months of dialysis. During this period, private health insurers are the primary payer and pay for the majority of dialysis-related costs. Private health insurers often pay substantially higher prices for dialysis care than does Medicare, possibly due to highly concentrated dialysis-provider markets. A perspective by Boumil and Curfmin in this journal discusses how a recent ruling by the US Supreme Court may limit Medicare's role as a secondary payer, potentially altering the economic relationship between dialysis providers and private insurers. Boumil and Curfmin discuss how these changes may ultimately promote competition in dialysis-provider markets and lower dialysis-related costs paid by private health insurers. We compare this viewpoint to responses and concerns voiced by other stakeholders in the kidney-care community and outline additional ways in which the Supreme Court's ruling may affect competition in dialysis markets and prices paid for dialysis by private insurers.
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Affiliation(s)
- Kevin F Erickson
- Section of Nephrology, Baylor College of Medicine, Houston, Texas; Baker Institute for Public Policy, Rice University, Houston Texas; Center for Innovations in Quality, Effectiveness and Safety, Baylor College of Medicine, Houston, Texas.
| | - Chase Eck
- Center for Innovations in Quality, Effectiveness and Safety, Baylor College of Medicine, Houston, Texas; Michael E. DeBakey VA Medical Center, Houston, Texas; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston Texas
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Adler JT, Husain SA, Xiang L, Rodrigue JR, Waikar SS. Initial Home Dialysis Is Increased for Rural Patients by Accessing Urban Facilities. KIDNEY360 2022; 3:488-496. [PMID: 35582180 PMCID: PMC9034801 DOI: 10.34067/kid.0006932021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/15/2021] [Indexed: 01/10/2023]
Abstract
Background The 240,000 rural patients with end stage kidney disease in the United States have less access to nephrology care and higher mortality than those in urban settings. The Advancing American Kidney Health initiative aims to increase the use of home renal replacement therapy. Little is known about how rural patients access home dialysis and the availability and quality of rural dialysis facilities. Methods Incident dialysis patients in 2017 and their facilities were identified in the United States Renal Data System. Facility quality and service availability were analyzed with descriptive statistics. We assessed the availability of home dialysis methods, depending on rural versus urban counties, and then we used multivariate logistic regression to identify the likelihood of rural patients with home dialysis as their initial modality and the likelihood of rural patients changing to home dialysis within 90 days. Finally, we assessed mortality after dialysis initiation on the basis of patient home location. Results Of the 97,930 dialysis initiates, 15,310 (16%) were rural. Rural dialysis facilities were less likely to offer home dialysis (51% versus 54%, P<0.001). Although a greater proportion of rural patients (9% versus 8%, P<0.001) were on home dialysis, this was achieved by traveling to urban facilities to obtain home dialysis (OR=2.74, P<0.001). After adjusting for patient and facility factors, rural patients had a higher risk of mortality (HR=1.06, P=0.004). Conclusions Despite having fewer facilities that offer home dialysis, rural patients were more often on home dialysis methods because they traveled to urban facilities, representing an access gap. Even if rural patients accessed home dialysis at urban facilities, rural patients still suffered worse mortality. Future dialysis policy should address this access gap to improve care and overall mortality for rural patients.
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Affiliation(s)
- Joel T. Adler
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Austin at Texas, Austin, Texas,Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, Massachusetts
| | - S. Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York,The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Lingwei Xiang
- Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, Massachusetts
| | - James R. Rodrigue
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Sushrut S. Waikar
- Department of Medicine, Boston Medical Center, Boston, Massachusetts
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6
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Erickson KF, Warrier A, Wang V. Market Consolidation and Innovation in US Dialysis. Adv Chronic Kidney Dis 2022; 29:65-75. [PMID: 35690407 DOI: 10.1053/j.ackd.2022.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 01/06/2022] [Accepted: 01/18/2022] [Indexed: 11/11/2022]
Abstract
While patients with end-stage kidney disease have benefited from innovations in clinical therapeutics and care delivery, these changes have been primarily incremental and have not fundamentally transformed care delivery. Dialysis markets are highly concentrated, which may impede innovation. Unique features of the dialysis industry that have contributed to consolidation can help to explain links between consolidation and innovation. We discuss these unique features and then provide a framework for considering the effects of consolidation on innovation in dialysis that focuses on the following economic considerations: (1) industry characteristics, composition, and stage of consolidation, (2) innovation characteristics and relative profitability, (3) the role of government regulation, and (4) innovation from smaller providers and new entrants. We present examples of how these considerations have influenced the adoption of alternative dialysis technologies such as peritoneal dialysis and erythropoietin-stimulating agents, and we discuss how consolidated markets can both help and hinder recent policy initiatives to transform dialysis care delivery. Only by considering these important drivers of consolidation, future efforts can be successful in transforming end-stage kidney disease care.
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Affiliation(s)
- Kevin F Erickson
- Baylor College of Medicine, Section of Nephrology, Houston, TX; Baker Institute for Public Policy, Rice University, Houston, TX.
| | - Anupama Warrier
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Virginia Wang
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC; Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, NC
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Parvathareddy V, Erickson KF. How Did Medicare Payment Reform Affect Highly Concentrated Dialysis Markets? JAMA HEALTH FORUM 2021; 2:e213378. [DOI: 10.1001/jamahealthforum.2021.3378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Kevin F. Erickson
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
- Baker Institute for Public Policy, Rice University, Houston, Texas
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Sloan CE, Hoffman A, Maciejewski ML, Coffman CJ, Trogdon JG, Wang V. Trends in Dialysis Industry Consolidation After Medicare Payment Reform, 2006-2016. JAMA HEALTH FORUM 2021; 2:e213626. [PMID: 35977264 PMCID: PMC8796909 DOI: 10.1001/jamahealthforum.2021.3626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 09/20/2021] [Indexed: 11/14/2022] Open
Abstract
Question Findings Meaning Importance Objective Design, Setting, and Participants Exposures Main Outcomes and Measures Results Conclusions and Relevance
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Affiliation(s)
- Caroline E. Sloan
- Department of Medicine, Duke University Health System, Durham, North Carolina
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, North Carolina
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Abby Hoffman
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matthew L. Maciejewski
- Department of Medicine, Duke University Health System, Durham, North Carolina
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Cynthia J. Coffman
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Justin G. Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Virginia Wang
- Department of Medicine, Duke University Health System, Durham, North Carolina
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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Adler JT, Xiang L, Weissman JS, Rodrigue JR, Patzer RE, Waikar SS, Tsai TC. Association of Public Reporting of Medicare Dialysis Facility Quality Ratings With Access to Kidney Transplantation. JAMA Netw Open 2021; 4:e2126719. [PMID: 34559227 PMCID: PMC8463939 DOI: 10.1001/jamanetworkopen.2021.26719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Improving the quality of dialysis care and access to kidney transplantation for patients with end-stage kidney disease is a national clinical and policy priority. The role of dialysis facility quality in increasing access to kidney transplantation is not known. OBJECTIVE To determine whether patient, facility, and kidney transplant waitlisting characteristics are associated with variations in dialysis center quality. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study is an analysis of US Renal Data System data and Medicare Dialysis Facility Compare (DFC) data from 2013 to 2018. Participants included all adult (aged ≥18 years) patients in the US Renal Data System beginning long-term dialysis in the US from 2013 to 2017 with follow-up through the end of 2018. Patients with a prior kidney transplant and matched Medicare DFC star ratings to each annual cohort of recipients were excluded. Patients at facilities without a star rating in that year were also excluded. Data analysis was performed from January to April 2021. EXPOSURES Dialysis center quality, as defined by Medicare DFC star ratings. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of patients undergoing incident dialysis who were waitlisted within 1 year of dialysis initiation. Secondary outcomes were patient and facility characteristics. RESULTS Of 507 581 patients beginning long-term dialysis in the US from 2013 to 2017, 291 802 (57.4%) were male, 266 517 (52.5%) were White, and the median (interquartile range) age was 65 (55-75) years. Of 5869 dialysis facilities in 2017, 132 (2.2%) were 1-star, 436 (7.4%) were 2-star, 2047 (34.9%) were 3-star, 1660 (28.3%) were 4-star, and 1594 (27.2%) were 5-star. Higher-quality dialysis facilities were associated with 47% higher odds of transplant waitlisting (odds ratio [OR], 1.47; 95% CI, 1.39-1.57 for 5-star facilities vs 1-star facilities; P < .001). Black patients were less likely than White patients to be waitlisted for transplantation (OR, 0.74; 95% CI, 0.72-0.76). In addition, patients at for-profit (OR, 0.78; 95% CI, 0.74-0.81) and rural (OR, 0.63; 95%, CI 0.58-0.68) facilities were less likely to be waitlisted for transplantation compared with those at nonprofit and urban facilities, respectively. CONCLUSIONS AND RELEVANCE In this cohort study, patients at higher-quality dialysis facilities had higher odds than patients at lower-quality facilities of being waitlisted for kidney transplantation within 1 year. Waitlisting rates for kidney transplantation should be considered for integration into the current Centers for Medicare & Medicaid Services DFC star ratings to incentivize dialysis facility referral to transplant centers, inform patient choice, and drive quality improvement by increasing transplant waitlisting rates.
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Affiliation(s)
- Joel T. Adler
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Lingwei Xiang
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Joel S. Weissman
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - James R. Rodrigue
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Rachel E. Patzer
- Department of Surgery, Emory Medical School, Atlanta, Georgia
- Department of Medicine, Emory Medical School, Atlanta, Georgia
| | - Sushrut S. Waikar
- Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Thomas C. Tsai
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Dickman S, Mirza R, Kandi M, Incze MA, Dodbiba L, Yameen R, Agarwal A, Zhang Y, Kamran R, Couban R, Guyatt G, Hanna S. Mortality at For-Profit Versus Not-For-Profit Hemodialysis Centers: A Systematic Review and Meta-analysis. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2020; 51:371-378. [PMID: 33323016 DOI: 10.1177/0020731420980682] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We conducted a systematic review and meta-analysis to assess differences in risk-adjusted mortality rates between for-profit (FP) and not-for-profit (NFP) hemodialysis facilities. We searched 10 databases for studies published between January 2001 to December 2019 that compared mortality at private hemodialysis facilities. We included observational studies directly comparing adjusted mortality rates between FP and NFP private hemodialysis providers in any language or country. We excluded evaluations of dialysis facilities that changed their profit status, studies with overlapping data, and studies that failed to adjust for patient age and some measure of clinical severity. Pairs of reviewers independently screened all titles and abstracts and the full text of potentially eligible studies, abstracted data, and assessed risk of bias, resolving disagreement by discussion. We included nine observational studies of hemodialysis facilities representing 1,163,144 patient-years. In pooled random-effects meta-analysis, the odds ratio of mortality in FP relative to NFP facilities was 1.07 (95% CI 1.04-1.11). Patients at FP hemodialysis facilities have 7 percent greater odds of death annually than patients with similar risk profiles at NFP facilities. Approximately 3,800 excess deaths might be averted annually if U.S. FP hemodialysis operators matched NFP mortality rates.
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Affiliation(s)
- Samuel Dickman
- Department of Medicine, University of California, San Francisco, California
| | - Reza Mirza
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Maryam Kandi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario
| | - Michael A Incze
- Department of Medicine, University of Utah, Salt Lake City, Utah
| | - Lorin Dodbiba
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Raad Yameen
- Department of Family Medicine, University of Winnipeg, Winnipeg, Manitoba, Canada
| | - Arnav Agarwal
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ying Zhang
- Center for Evidence-based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Rakhshan Kamran
- Michael Degroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rachel Couban
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Steven Hanna
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario
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11
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Erickson KF, Shen JI, Zhao B, Winkelmayer WC, Chertow GM, Ho V, Bhattacharya J. Safety-Net Care for Maintenance Dialysis in the United States. J Am Soc Nephrol 2020; 31:424-433. [PMID: 31857351 PMCID: PMC7003304 DOI: 10.1681/asn.2019040417] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 10/18/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Although most American patients with ESKD become eligible for Medicare by their fourth month of dialysis, some never do. Information about where patients with limited health insurance receive maintenance dialysis has been lacking. METHODS We identified patients initiating maintenance dialysis (2008-2015) from the US Renal Data System, defining patients as "safety-net reliant" if they were uninsured or had only Medicaid coverage at dialysis onset and had not qualified for Medicare by the fourth dialysis month. We examined four dialysis facility ownership categories according to for-profit/nonprofit status and ownership (chain versus independent). We assessed whether patients who were safety-net reliant were more likely to initiate dialysis at certain facility types. We also examined hospital-based affiliation. RESULTS The proportion of patients <65 years initiating dialysis who were safety-net reliant increased significantly over time, from 11% to 14%; 73% of such patients started dialysis at for-profit/chain-owned facilities compared to 76% of all patients starting dialysis. Patients who were safety-net reliant had a 30% higher relative risk of initiating dialysis at nonprofit/independently owned versus for-profit/independently owned facilities (odds ratio, 1.30; 95% CI, 1.24 to 1.36); they had slightly lower relative risks of initiating dialysis at for-profit and non-profit chain-owned facilities, and were more likely to receive dialysis at hospital-based facilities. These findings primarily reflect increased likelihood of dialysis among patients without insurance at certain facility types. CONCLUSIONS Although most patients who were safety-net reliant received care at for-profit/chain-owned facilities, they were disproportionately cared for at nonprofit/independently owned and hospital-based facilities. Ongoing loss of market share of nonprofit/independently owned outpatient dialysis facilities may affect safety net-reliant populations.
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Affiliation(s)
- Kevin F Erickson
- Selzman Institute for Kidney Health, Section of Nephrology, and
- Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, Houston, Texas
- Baker Institute for Public Policy, Rice University, Houston, Texas
| | - Jenny I Shen
- Los Angeles Biomedical Research Institute at Harbor-University of California, Los Angeles Medical Center, Torrance, California
| | - Bo Zhao
- Selzman Institute for Kidney Health, Section of Nephrology, and
| | | | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Vivian Ho
- Baker Institute for Public Policy, Rice University, Houston, Texas
| | - Jay Bhattacharya
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California
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12
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Affiliation(s)
| | - Melina R. Kibbe
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill
- Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill
- Editor, JAMA Surgery
| | - David A. Gerber
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill
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13
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Boulware LE, Wang V, Powe NR. Improving Access to Kidney Transplantation: Business as Usual or New Ways of Doing Business? JAMA 2019; 322:931-933. [PMID: 31503296 DOI: 10.1001/jama.2019.12784] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- L Ebony Boulware
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
- Center for Health Outcomes and Innovation Research, Duke University School of Medicine, Durham, North Carolina
| | - Virginia Wang
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health System, Durham, North Carolina
| | - Neil R Powe
- Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco
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14
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Cohen JB, Potluri V, Porrett PM, Chen R, Roselli M, Shults J, Sawinski DL, Reese PP. Leveraging marginal structural modeling with Cox regression to assess the survival benefit of accepting vs declining kidney allograft offers. Am J Transplant 2019; 19:1999-2008. [PMID: 30725536 PMCID: PMC6591028 DOI: 10.1111/ajt.15290] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 01/09/2019] [Accepted: 01/16/2019] [Indexed: 01/25/2023]
Abstract
Existing studies evaluating the survival benefit of kidney transplantation were unable to incorporate time-updated information on decisions related to each organ offer. We used national registry data, including organ turndown data, to evaluate the survival benefit of accepting vs turning down kidney offers in candidates waitlisted from 2007-2013. Among candidates who declined their first offer, only 43% ultimately received organ transplantations. Recipients who later underwent organ transplantation after declining their first offer had markedly longer wait times than recipients who accepted their first offer, and 56% received kidney transplants that were of similar or lower quality compared to their initial offer. In marginal structural modeling analyses accounting for time-updated offer characteristics (including Kidney Donor Profile Index, Public Health System risk status, and pumping), after 3 months posttransplant, there was a significant survival benefit of accepting an offer (adjusted hazard ratio 0.76, 95% confidence interval 0.66-0.89) that was similar among diabetics, candidates aged >65 years, and candidates living in donor service areas with the longest waitlist times. After carefully accounting for the effect of donor quality, we confirm that the survival benefit of accepting an organ offer is clinically meaningful and persistent beyond 3 months post-kidney transplantation, including high-risk subgroups of organ transplantation candidates.
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Affiliation(s)
- Jordana B. Cohen
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vishnu Potluri
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paige M. Porrett
- Division of Transplant Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ruohui Chen
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marielle Roselli
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Justine Shults
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Deirdre L. Sawinski
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter P. Reese
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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15
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Erickson KF, Zhao B, Niu J, Winkelmayer WC, Bhattacharya J, Chertow GM, Ho V. Association of Hospitalization and Mortality Among Patients Initiating Dialysis With Hemodialysis Facility Ownership and Acquisitions. JAMA Netw Open 2019; 2:e193987. [PMID: 31099872 PMCID: PMC6537810 DOI: 10.1001/jamanetworkopen.2019.3987] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Mergers and acquisitions among health care institutions are increasingly common, and dialysis markets have undergone several decades of mergers and acquisitions. OBJECTIVE To examine the outcomes of hemodialysis facility acquisitions independent of associated changes in market competition resulting from acquisitions. DESIGN, SETTING, AND PARTICIPANTS Cohort study using difference-in-differences (DID) analyses to compare changes in health outcomes over time among in-center US dialysis facilities that were acquired by a hemodialysis chain with facilities located nearby but not acquired. Multivariable Cox proportional hazards regression models and negative binomial models with predicted marginal effects were developed to examine health outcomes, controlling for patient, facility, and geographic characteristics. All facility ownership types were examined together and stratified analyses were conducted of facilities that were independently owned and chain owned prior to acquisitions. The study was conducted from January 2001 to September 2015; 174 905 patients starting in-center dialysis in the 3 years before and following dialysis facility acquisitions were included. Data were analyzed from March 2017 to December 2018. EXPOSURES Acquisition by a hemodialysis chain. MAIN OUTCOMES AND MEASURES Twelve-month hazard of death and hospital days per patient-year were the primary outcomes. RESULTS Of the 174 905 patients included in the study, 79 705 were women (45.6%), 24 409 (14.0%) were of Hispanic ethnicity, 61 815 (35.3%) were black, 105 272 (60.2%) were white, and 1247 (0.7%) were Native American. Mean (SD) age was 65 (15) years. Before acquisitions, adjusted mortality and hospitalization rates were 10% (95% CI, -16% to -5%) and 2.9 days per patient-year (95% CI, -3.8 to -2.0) lower, respectively, at independently owned facilities that were acquired compared with those that were not acquired, while hospitalization rates were 0.7 days (95% CI, -1.2 to -2.0) lower at chain-owned facilities that were acquired compared with those that were not acquired. In stratified analyses of independently owned facilities, mortality decreases were smaller at acquired (-8.4%; 95% CI, -14% to -25%) vs nonacquired (-20.3%; 95% CI, -25.8% to -14.3%) facilities (DID P < .001). Similarly, hospitalization rates did not change at acquired facilities and decreased by 2.6 days per patient-year (95% CI, -3.6 to -1.7 days) at nonacquired facilities (DID P < .001). Acquisitions were not associated with changes in health outcomes at chain-owned facilities. Slower reductions in mortality and hospitalization rates at independently owned facilities contributed to significant differences in hospitalizations (-2.0 days; 95% CI, -2.5 to -1.6, at nonacquired vs 0.9 days; 95% CI, -1.3 to -0.5, at acquired facilities; DID, P < .001) across all ownership types but not mortality (DID, P = .28) with regard to acquisitions. CONCLUSIONS AND RELEVANCE Acquisition of independently owned dialysis facilities by larger dialysis organizations was associated with slower decreases in mortality and hospitalization rates, as nonacquired facilities appeared to experience more rapid improvements in outcomes over time.
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Affiliation(s)
- Kevin F Erickson
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
- Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, Houston, Texas
- Baker Institute for Public Policy, Rice University, Houston, Texas
| | - Bo Zhao
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Jingbo Niu
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | | | - Jay Bhattacharya
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Vivian Ho
- Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, Houston, Texas
- Baker Institute for Public Policy, Rice University, Houston, Texas
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16
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Erickson KF, Winkelmayer WC, Ho V, Bhattacharya J, Chertow GM. Market Consolidation and Mortality in Patients Initiating Hemodialysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:69-76. [PMID: 30661636 PMCID: PMC6740331 DOI: 10.1016/j.jval.2018.06.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 05/31/2018] [Accepted: 06/11/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND It is uncertain whether consolidation in health care markets affects the quality of care provided and health outcomes. OBJECTIVES To examine whether changes in market competition resulting from acquisitions by two large national for-profit dialysis chains were associated with patient mortality. METHODS We identified patients initiating in-center hemodialysis between 2001 and 2009 from a registry of patients with end-stage renal disease in the United States. We considered two scenarios when evaluating consolidation from dialysis facility acquisitions: one in which we considered only those patients receiving dialysis in markets that became substantially more concentrated to have been affected by consolidation, and the other in which all patients living in hospital service areas where a facility was acquired were potentially affected. We used a difference-in-differences study design to examine the associations between market consolidation and changes in mortality rates. RESULTS When we considered the 12,065 patients living in areas that became substantially more consolidated to have been affected by consolidation, we found a nominally significant (8%; 95% confidence interval 0%-17%) increase in likelihood of death after consolidation. Nevertheless, when we considered all 186,158 patients living in areas where an acquisition occurred to have been affected by consolidation, there was no observable effect of market consolidation on mortality. CONCLUSIONS Decreased market competition may have led to increased mortality among a relatively small subset of patients initiating in-center hemodialysis in areas that became substantially more concentrated after two large dialysis acquisitions, but not for most of the patients living in affected areas.
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Affiliation(s)
- Kevin F Erickson
- Section of Nephrology and Selzman Institute for Kidney Health, Houston, TX, USA; Baylor College of Medicine, Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX, USA; Baker Institute for Public Policy, Rice University, Houston, TX, USA.
| | | | - Vivian Ho
- Baylor College of Medicine, Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX, USA; Baker Institute for Public Policy, Rice University, Houston, TX, USA
| | - Jay Bhattacharya
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA, USA
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
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17
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Brady BM, Zhao B, Niu J, Winkelmayer WC, Milstein A, Chertow GM, Erickson KF. Patient-Reported Experiences of Dialysis Care Within a National Pay-for-Performance System. JAMA Intern Med 2018; 178:1358-1367. [PMID: 30208398 PMCID: PMC6233760 DOI: 10.1001/jamainternmed.2018.3756] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE Medicare's End-Stage Renal Disease Quality Incentive Program incorporates measures of perceived value into reimbursement calculations. In 2016, patient experience became a clinical measure in the Quality Incentive Program scoring system. Dialysis facility performance in patient experience measures has not been studied at the national level to date. OBJECTIVE To examine associations among dialysis facility performance with patient experience measures and patient, facility, and geographic characteristics. DESIGN In this cross-sectional analysis, patients from a national end-stage renal disease registry receiving in-center hemodialysis in the United States on December 31, 2014, were linked with dialysis facility scores on the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS) survey. Of 4977 US dialysis facilities, 2939 (59.1%) reported ICH-CAHPS scores from April 8, 2015, through January 11, 2016. Multivariable linear regression models with geographic random effects were used to examine associations of facility ICH-CAHPS scores with patient, dialysis facility, and geographic characteristics and to identify the amount of total between-facility variation in patient experience scores explained by these categories. Data were analyzed from September 15, 2017, through June 1, 2018. EXPOSURES Dialysis facility, geographic characteristic, and 10% change in patient characteristics. MAIN OUTCOMES AND MEASURES Dialysis facility ICH-CAHPS scores and the total between-facility variation explained by different categories of characteristics. RESULTS Of the 2939 facilities included in the analysis, adjusted mean ICH-CAHPS scores were 2.6 percentage points (95% CI, 1.5-3.7) lower in for-profit facilities, 1.6 percentage points (95% CI, 0.9-2.2) lower in facilities owned by large dialysis organizations, and 2.3 percentage points (95% CI, 0.5-4.2) lower in free-standing facilities compared with their counterparts. More nurses per patient was associated with 0.2 percentage points (95% CI, 0.03-0.3) higher scores; a privately insured patient population was associated with 1.2 percentage points (95% CI, 0.2-2.2) higher scores. Facilities with higher proportions of black patients had 0.95 percentage points (95% CI, 0.78-1.12) lower scores; more Native American patients, 1.00 percentage point (95% CI, 0.39-1.60) lower facility scores. Geographic location and dialysis facility characteristics explained larger proportions of the overall between-facility variation in ICH-CAHPS scores than did patient characteristics. CONCLUSIONS AND RELEVANCE This study suggests that for-profit operation, free-standing status, and large dialysis organization designation were associated with less favorable patient-reported experiences of care. Patient experience scores varied geographically, and black and Native American populations reported less favorable experiences. The study findings suggest that perceived quality of care delivered in these settings are of concern, and that there may be opportunities for improved implementation of patient experience surveys as is highlighted.
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Affiliation(s)
- Brian M Brady
- Division of Nephrology, Stanford University School of Medicine, Stanford, California.,Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, California
| | - Bo Zhao
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Jingbo Niu
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Arnold Milstein
- Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, California
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Kevin F Erickson
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas.,Baker Institute for Public Policy, Rice University, Houston, Texas
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18
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Erickson KF, Qureshi S, Winkelmayer WC. The Role of Big Data in the Development and Evaluation of US Dialysis Care. Am J Kidney Dis 2018; 72:560-568. [PMID: 29921451 DOI: 10.1053/j.ajkd.2018.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 04/07/2018] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Kevin F Erickson
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX; Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, Houston, TX; Baker Institute for Public Policy, Rice University, Houston, TX.
| | - Samaya Qureshi
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX
| | - Wolfgang C Winkelmayer
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX
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19
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Erickson KF, Zheng Y, Ho V, Winkelmayer WC, Bhattacharya J, Chertow GM. Market Competition and Health Outcomes in Hemodialysis. Health Serv Res 2018; 53:3680-3703. [PMID: 29468675 DOI: 10.1111/1475-6773.12835] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine whether market competition is associated with improved health outcomes in hemodialysis. DATA SOURCES Secondary analysis of data from a national dialysis registry between 2001 and 2011. STUDY DESIGN We conducted one- and two-part linear regression models, using each hospital service area (HSA) as its own control, to examine the independent associations among market concentration and health outcomes. DATA COLLECTION We selected cohorts of patients receiving in-center hemodialysis in the United States at the start of each calendar year. We used information about dialysis facility ownership and the location where patients received dialysis to measure an index of market concentration-the Hirschman-Herfindahl Index (HHI)-for HSA and year, which ranges from near zero (perfect competition) to one (monopoly). PRINCIPAL FINDINGS An average reduction in HHI by 0.2 (one standard deviation in 2011) was associated with 2.9 fewer hospitalizations per 100 patient-years (95 percent CI, 0.4 to 5.4). If these findings were generalized to the entire in-center hemodialysis population, this would translate to 8,100 (95 percent CI 1,200 to 15,000) fewer hospitalizations in 2011. There was no association between change in market competition and mortality. CONCLUSIONS Market competition in dialysis may lead to improved health outcomes.
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Affiliation(s)
- Kevin F Erickson
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX.,Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX.,Baker Institute for Public Policy, Rice University, Houston, TX
| | - Yuanchao Zheng
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - Vivian Ho
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX.,Baker Institute for Public Policy, Rice University, Houston, TX
| | - Wolfgang C Winkelmayer
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX
| | - Jay Bhattacharya
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
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20
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Cohen J, Shults J, Goldberg D, Abt P, Sawinski D, Reese P. Kidney allograft offers: Predictors of turndown and the impact of late organ acceptance on allograft survival. Am J Transplant 2018; 18:391-401. [PMID: 28758329 PMCID: PMC5790617 DOI: 10.1111/ajt.14449] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 07/19/2017] [Accepted: 07/23/2017] [Indexed: 01/25/2023]
Abstract
There is growing interest in understanding patterns of organ acceptance and reducing discard. Little is known about how donor factors, timing of procurement, and geographic location affect organ offer decisions. We performed a retrospective cohort study of 47 563 deceased donor kidney match-runs from 2007 to 2013. Several characteristics unrelated to allograft quality were independently associated with later acceptance in the match-run: Public Health Service increased-risk donor status (adjusted odds ratio [aOR] 2.49, 95% confidence interval [CI] 2.29-2.69), holiday or weekend procurement (aOR 1.11, 95% CI 1.07-1.16), shorter donor stature (aOR 1.53 for <150 cm vs reference >180 cm, 95% CI 1.28-1.94), and procurement in an area with higher intensity of market competition (aOR 1.71, 95% CI 1.62-1.78) and with the longest waiting times (aOR 1.41, 95% CI 1.34-1.49). Later acceptance in the match-run was associated with delayed graft function but not all-cause allograft failure (adjusted hazard ratio 1.01, 95% CI 0.96-1.07). Study limitations include a lack of match-run data for discarded organs and the possibility of sequence inaccuracies for some nonlocal matches. Interventions are needed to reduce turndowns of viable organs, especially when decisions are driven by infectious risk, weekend or holiday procurement, geography, or other donor characteristics unrelated to allograft quality.
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Affiliation(s)
- J.B. Cohen
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA, USA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - J. Shults
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - D.S. Goldberg
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA,Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA, USA
| | - P.L. Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - D.L. Sawinski
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA, USA
| | - P.P. Reese
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA, USA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
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21
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Kshirsagar AV, Manickam RN, Mu Y, Flythe JE, Chin AI, Bang H. Area-level poverty, race/ethnicity & dialysis star ratings. PLoS One 2017; 12:e0186651. [PMID: 29040342 PMCID: PMC5645143 DOI: 10.1371/journal.pone.0186651] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 09/25/2017] [Indexed: 11/25/2022] Open
Abstract
The Centers for Medicare and Medicaid Services recently released a five star rating system as part of ‘Dialysis Facility Compare’ to help patients identify and choose high performing clinics in the US. Eight dialysis-related measures determine ratings. Little is known about the association between surrounding community sociodemographic characteristics and star ratings. Using data from the U.S. Census and over 6000 dialysis clinics across the country, we examined the association between dialysis clinic star ratings and characteristics of the local population: 1) proportion of population below the federal poverty level (FPL); 2) proportion of black individuals; and 3) proportion of Hispanic individuals, by correlation and regression analyses. Secondary analyses with Quality Incentive Program (QIP) scores and population characteristics were also performed. We observed a negligible correlation between star ratings and the proportion of local individuals below FPL; Spearman coefficient, R = -0.09 (p<0.0001), and a stronger correlation between star ratings and the proportion of black individuals; R = -0.21 (p<0.0001). Ordered logistic regression analyses yielded adjusted odds ratio of 0.91 (95% confidence interval [0.80–1.30], p = 0.12) and 0.55 ([0.48–0.63], p<0.0001) for high vs. low level of proportion below FPL and proportion of black individuals, respectively. In contrast, a near-zero correlation was observed between star ratings and the proportion of Hispanic individuals. Correlations varied substantially by country region, clinic profit status and clinic size. Analyses using clinic QIP scores provided similar results. Sociodemographic characteristics of the surrounding community, factors typically outside of providers’ direct control, have varying levels of association with clinic dialysis star ratings.
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Affiliation(s)
- Abhijit V. Kshirsagar
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Raj N. Manickam
- Graduate Group in Epidemiology, University of California, Davis, Davis, California, United States of America
| | - Yi Mu
- Graduate Group in Epidemiology, University of California, Davis, Davis, California, United States of America
| | - Jennifer E. Flythe
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Andrew I. Chin
- Division of Nephrology, University of California, Davis School of Medicine, Sacramento, California, United States of America
- Division of Nephrology, Sacramento VA Medical Center, VA Northern California Health Care Systems, Mather Field, California, United States of America
| | - Heejung Bang
- Graduate Group in Epidemiology, University of California, Davis, Davis, California, United States of America
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, Davis, California, United States of America
- Center for Healthcare Policy and Research, School of Medicine, University of California, Sacramento, Sacramento, California, United States of America
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