Do health outcomes vary by profit status of hemodialysis units?

In this issue of CJASN, Dalrymple et al. report the timely and potentially provocative results of their study comparing hospitalization rates among forprofit and nonprofit dialysis facilities (1). On the basis of their analysis of US Renal Data System (USRDS) data from Medicare beneficiaries starting dialysis between 2005 and 2008, they found that overall hospitalization rates were significantly higher (15% higher) for patients receiving hemodialysis in for-profit compared with nonprofit dialysis facilities. In addition, for-profit dialysis facilities had higher admission rates for heart failure and volume overload (37% higher) aswell as vascular access complications (15% higher) compared with nonprofit facilities. Of note, there was no difference in hospitalization rates of patients receiving home peritoneal dialysis related to the provider for-profit/nonprofit status.Homehemodialysis patientswerenot included in the study. The relationship of for-profit versus nonprofit status in health outcomes has long been an intense health policy issue in the hospital sector, with persistent Congressional and Office of the Inspector General scrutiny of for-profit/nonprofit status of hospitals, as well as a recent increase in hospital conversions from nonprofit to for-profit status. Nonprofit hospitals account for 58% of all US community hospitals and 74% of all nongovernmental US community hospitals (2). Although many studies have compared hospital for-profit/nonprofit status on health outcomes, the findings are mixed and inconsistent. Nonprofit dialysis facilities, on the other hand, comprise only 15% of United States dialysis facilities; 85% of facilities are classified as for-profit, with two large for-profit dialysis organizations controlling over two thirdsofUnitedStatesdialysis facilities (3). Thenumber of dialysis facilities nationwide has been steadily increasing, with growth in the percentage of for-profit dialysis facilities mirroring that increase. Given the intense national scrutiny of the for-profit/nonprofit status implications in the hospital sector, it is surprising that health policy interest regarding this issue in the dialysis sector has not been as robust. Dalrymple et al. reference a relatively small number of prior studies examining for-profit status effects on health outcomes of dialysis patients,most prior studies focused on mortality rates and concluded that mortality rates were higher among beneficiaries receiving dialysis treatments at for-profit facilities compared with nonprofit facilities (4,5). In addition, other studies have shown greater utilization of erythropoiesisstimulating agents in for-profit versus nonprofit facilities (6), decreased rates of listing for transplantation in for-profit facilities (7), and decreased transplant education time with nephrologists at for-profit compared with nonprofit dialysis facilities (8). Most of those studies predated by years the January 1, 2011, implementation of the Medicare ESRD Bundled Prospective Payment System (PPS) and Quality Incentive Program (QIP). This raises the question of their current relevance under a different reimbursement system that is increasingly dominated by two huge corporate organizations, as well as a diminishing number of nonprofit competitors. Critics cite concerns about study methodologies and data interpretations. However, growing general opinion appears to suggest that nonprofit dialysis organizations may have lower mortality and hospitalization rates, as well as higher transplantation rates, compared with for-profit counterparts. Dalrymple et al. add to that general opinion. However, every new study on this topic has been qualified by a call for further studies needing to be performed. Although the authors refer briefly to USRDS data reports, there is information to be considered from the USRDS regarding the importance and possible relationship between hospitalizations, aswell asmortality, and for-profit status of treating dialysis facilities. The USRDS annual data reports (ADRs) have focused on all-cause and cause-specific hospitalizations over the past few years as part of the USRDS’s morbidity surveillance functions. All-cause admissions and hospital days have been steadily falling over the past decade, with hemodialysis patient cause-specific rates mirroring the all-cause rates. The same is true for declining mortality rates over the past decade. Cause-specific admission/hospital day rates reveal amarked increase in infectious causes of both metrics, particularly for the in-center hemodialysis population (9). Furthermore, 36% of ESRD patients discharged from an all-cause admission were readmitted to a hospital within 30 days. This markedly exceeds the readmission rate within 30 days of discharge for all Medicare patients (20%) (10). This is especially significant when one considers that ESRDpatients are seen three times perweek and should have multiple opportunities to address Barry M. Straube, M.D. Consulting LLC, Baltimore, Maryland