The other shoe dropped?

A few months ago, I reported that a feeling I had for years is now backed up by data. I’m talking about the Dr. Erickson et. al. study which demonstrated that when chains take over independent dialysis clinics, patient care is compromised.  In particular, patient mortality and hospitalization rates were worse after the merger.

Now, another study, also published in JAMA (the Journal of the American Medical Association) provides data demonstrating that for-profit dialysis centers are less likely to enable their patients to undergo a transplant.

The researchers, from Emory (Dr. Rachel Patzer, senior author with Katherine Ross, Laura McPherson, and Elizabeth Walker, plus Drs. Adam Wilk, Stephen Pastan, Zhensheng Wang), U of Michigan (Dr. Xingyu Zhang), U of South Carolina (Dr. Teri Browne)  and Kaiser Permanente (Dr. Jennifer Gander, the lead author), examined the USRDS (United States Renal Data System), a comprehensive compendium of all things renal in the USA.  In particular, the data from almost 1.5 million patients (1478564) undergoing treatments over the years 2000 through 2016 (at 6511 dialysis centers) was examined for dialysis regimen and kidney transplants.  (The researchers also needed data from Dialysis Facility Compare [reporting the for-profit and ownership status of dialysis clinics) and Dialysis Facility Report (treatment patterns and transplantation rates) to complete the analysis.)

As a check for the validity of the data, the researchers determined that the insurance coverage for those being dialyzed at for-profit and non-profit centers was similar, as were patient co-morbidities; as such, these could not be factors affecting  the results.

Only about 8.2% of the patient census was found to be on the transplant waiting list (121,680 patients) for a deceased-donor transplant- and  about half (4.9%) of that total received a transplant.  Interestingly, 1.6% (23762) got their grafts from living donors and 3.3% (49290) from deceased donors. Yet another tidbit was that about 8.9% of the 1.5 million cohort were being treated at home- and these patients were far more likely to undergo transplantation than the in-center patients.

The delineations the study examined was fairly comprehensive.  They separated the patients by those receiving dialysis in large chains (>1000 for-profit centers), small chains (<1000 for-profit centers), for-profit independent centers, as well as non-profit independent centers.  Moreover, non-profit small chains were also separated out in the census.  While the report indicated that 87% of the patients were getting their care at for-profit facilities, that should not be terribly surprising.   After all, DaVita and Fresenius control 77% of all the centers, with 92% of all revenue passing through their coffers.

Those transplant numbers in the first table above need a little bit of explanation for those of you who aren’t involved in dialysis.  Since the for-profit centers rely on many patients to be treated in the center, they are presumed to be reluctant to recommend a patient for transplant; their patients, therefore, end up being on the list for shorter periods.  The non-profit centers, where revenue is not the driving force, are willing to recommend patients for transplant earlier, hoping they can be free of dialysis with a transplanted kidney; as such, their patients end up longer on the transplant list.  (You do recall that we have insufficient numbers of donated kidneys, right?)

(If we are able to provide a transplant, the costs are much cheaper (over the long term) than a dialysis regimen, plus it’s far less burdensome for the patient and provides better survival chances than dialysis. But, the reimbursement system provides no financial incentives for dialysis providers to educate and refer patients for transplant.  [TheDonald’s executive order should change this factor soon.])

This is the reason why the researchers recommend that dialysis patients become firm advocates for their own transplant.