For-Profit U.S. Dialysis Facilities Show Higher Patient Death Rates Than Non-Profits, JAMA Study Shows

HAMILTON, ONT. -- The profit motive that drives U.S. for-profit kidney dialysis centers results in an average of 2,500 premature deaths annually, a study to be published tomorrow (Nov. 20, 2002) in the Journal of the American Medical Association (JAMA) has found.

The study's results also were presented today at a press conference in Washington, D.C., sponsored by the non-profit Public Citizen's Health Research Group.

The findings are based on a systematic review and meta-analysis of eight observational studies involving data from for-profit or private not-for-profit American dialysis facilities covering more than 500,000 patient-years. It was conducted by researchers at McMaster University in Hamilton, Ont., and the University at Buffalo.

Results showed an 8 percent increase in death rates for dialysis patients treated in for-profit facilities compared to private not-for-profit care.

"The results are not difficult to explain," said P.J. Devereaux, Ph.D., research fellow in the departments of Medicine and Clinical Epidemiology and Biostatistics at McMaster University and lead author on the study. "Private for-profit facilities have to generate profits to satisfy shareholders and pay taxes. Typically these two expenditures are in the range of 10-15 percent of expenses.

"Not-for-profit facilities can spend this money on patient care. The higher death rates result when for-profit companies cut corners to make sure they produce the required profit margin."

Holger Schunemann, M.D., Ph.D., UB assistant professor of medicine and social and preventive medicine, and principal U.S. author, said: "While an 8 percent increase in mortality may seem small, the observed increase in mortality represents between 1,200 and 4,000 additional deaths annually. Our results indicate that for-profit dialysis centers provide lower quality care compared to not-for-profit centers.

The dialysis research follows a study published by the same group in the May 28 issue of the Canadian Medical Association Journal (CMAJ) that compared mortality rates in for-profit

hospitals versus not-for-profit hospitals. That study also found that patients faced a higher risk of dying when hospitalized in for-profit institutions.

Dialysis is a process that filters toxins and excess water from the blood. It is essential for people with kidney failure whose kidneys have ceased to do that job. The primary method of accomplishing this detoxification uses an apparatus called an artificial kidney, through which the blood circulates, is filtered and cleansed. About 200,000 Americans suffer from chronic kidney failure and need an artificial kidney machine to stay alive, according to the National Kidney Foundation.

The process is time-consuming -- standard treatment involves four hour of dialysis three times a week during the patient's lifetime, absent a kidney transplant -- and expensive, estimated at $45,000 to $50,000 a year. Medicare has paid for kidney dialysis in the U.S. since 1973.

Currently 75 percent of U.S. hemodialysis patients receive treatment at private for-profit facilities, 20 percent at private not-for-profit facilities, according to the current study. The remainder are treated at public hospitals or clinics, which were not included in the analysis.

The eight studies involved in this systematic review and meta-analysis took place from 1973-97, and included a median of 1,342 centers per study. Six of the eight studies showed a statistically significant increase in mortality in for-profit facilities, one study showed increased mortality in for-profits that didn't reach statistical significance, and one study showed a non-significant trend toward decreased mortality in for-profits.

Schunemann said individual studies comparing for-profit and not-for-profit dialysis outcomes have pointed to various possible reasons for the increased mortality risk

"Some studies show that for-profit dialysis centers employ fewer and less highly skilled personnel, such as licensed practical nurses, aids and technicians, instead of registered nurses," he said. "Other studies have indicated that patients at private for-profit centers receive shorter treatments, which are associated with higher mortality."

Devereaux said the results should raise serious concerns about private for-profit care, whether in dialysis facilities or hospitals. "It's time to move health care policy away from ideology and into the evidence-based era," he said.

Researchers from the University of Toronto, University of Western Ontario and the Canadian Institute for Advanced Research also contributed to the study.