title: Associations between CMS's Clinical Performance Measures project benchmarks, profit structure, and mortality in dialysis units.
abstract: Prior studies observing greater mortality in for-profit dialysis units have not captured information about benchmarks of care. This study was undertaken to examine the association between profit status and mortality while achieving benchmarks. Utilizing data from the US Renal Data System and the Centers for Medicare & Medicaid Services' end-stage renal disease (ESRD) Clinical Performance Measures project, hemodialysis units were categorized as for-profit or not-for-profit. Associations with mortality at 1 year were estimated using Cox regression. Two thousand six hundred and eighty-five dialysis units (31,515 patients) were designated as for-profit and 1018 (15,085 patients) as not-for-profit. Patients in for-profit facilities were more likely to be older, black, female, diabetic, and have higher urea reduction ratio (URR), hematocrit, serum albumin, and transferrin saturation. Patients (19.4 and 18.6%) in for-profit and not-for-profit units died, respectively. In unadjusted analyses, profit status was not associated with mortality (hazard ratio (HR)=1.04, P=0.09). When added to models with profit status, the following resulted in a significant association between profit status (for-profit vs not-for-profit) and increasing mortality risk: URR, hematocrit, albumin, and ESRD Network. In adjusted models, patients in for-profit facilities had a greater death risk (HR 1.09, P=0.004). More patients in for-profit units met clinical benchmarks. Survival among patients in for-profit units was similar to not-for-profit units. This suggests that in the contemporary era, interventions in for-profit dialysis units have not impaired their ability to deliver performance benchmarks and do not affect survival.
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina 27710, USA. szcze001@mc.duke.edu
authors.forename: L A
authors.initials: LA
authors.lastname: Szczech
authors.forename: P S
authors.initials: PS
authors.lastname: Klassen
authors.forename: B
authors.initials: B
authors.lastname: Chua
authors.forename: S S
authors.initials: SS
authors.lastname: Hedayati
authors.forename: M
authors.initials: M
authors.lastname: Flanigan
authors.forename: W M
authors.initials: WM
authors.lastname: McClellan
authors.forename: D N
authors.initials: DN
authors.lastname: Reddan
authors.forename: R A
authors.initials: RA
authors.lastname: Rettig
authors.forename: D L
authors.initials: DL
authors.lastname: Frankenfield
authors.forename: W F
authors.initials: WF
authors.lastname: Owen
mesh_terms: D000554:Ambulatory Care Facilities; D019985:Benchmarking; D005260:Female; D005500:Follow-Up Studies; D006436:Hemodialysis Units, Hospital; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D017149:Private Sector; D017150:Public Sector; D006435:Renal Dialysis / Q000401:mortality* / Q000592:standards*