Background More than 200,000 patients with end-stage renal diseaseundergo dialysis in the United States each year, about two thirdsin for-profit centers. Economic pressures, such as the declinein inflation-adjusted Medicare payments for dialysis, may compromisethe quality of care. Facilities may also be reluctant to referpatients to be evaluated for transplantation because of theloss of revenues from dialysis after patients receive transplants.It is unknown whether for-profit facilities respond more aggressivelythan not-for-profit facilities to these financial pressures.Therefore, we examined the effect of for-profit ownership ofdialysis facilities on patients' survival and referral for possibletransplantation.
Methods We used data from the U.S. Renal Data System to assemblea nationally representative cohort of patients with end-stagerenal disease of recent onset. We followed patients for a minimumof three years and a maximum of six years, until death, placementon the waiting list for a renal transplant, or loss to follow-up,or until May 31, 1996. We used proportional-hazards models toassess the effect of the profit status of the dialysis facilityon 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 theanalysis of the waiting list. The crude mortality rate per 100person-years of end-stage renal disease was 21.2 for patientstreated in for-profit facilities and 17.1 for patients treatedin not-for-profit centers (adjusted relative hazard, 1.20; 95percent confidence interval, 1.02 to 1.42). The likelihood ofbeing placed on the waiting list for a renal transplant waslower for patients treated at for-profit centers (adjusted relativehazard, 0.74; 95 percent confidence interval, 0.56 to 0.98).
Conclusions In the United States, for-profit ownership of dialysisfacilities, as compared with not-for-profit ownership, is associatedwith increased mortality and decreased rates of placement onthe waiting list for a renal transplant.
Source Information
From the Robert Wood Johnson Clinical Scholars Program (P.P.G., M.D.-W., N.R.P.) and the Departments of Medicine (P.P.G., N.R.P.), Health Policy and Management (K.D.F., N.R.P.), Biostatistics (M.D.-W.), and Epidemiology (N.R.P.), Johns Hopkins University, Baltimore. Presented in part at the 22nd Annual Meeting of the Society of General Internal Medicine, San Francisco, April 29–May 1, 1999, and at the 16th Annual Meeting of the Association for Health Services Research, Chicago, June 27–29, 1999.
Address reprint requests to Dr. Garg at the Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave., Boston, MA 02115-5899, or at garg{at}hcp.med.harvard.edu.
Ownership of Dialysis Facilities and Patients' Survival
Port F. K., Wolfe R. A., Held P. J., Bander S. J., Lazarus J. M., Lindenfeld S. M., Nissenson A. R., Owen W. F., Qunibi W. Y., Riley D. J., Abboud H. E., Ruma J. J., Wick G. S., Garg P. P., Frick K. D., Powe N. R.
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N Engl J Med 2000;
342:1053-1056, Apr 6, 2000.
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