title: Organizational status of dialysis facilities and patient outcome: does higher injectable medication use mediate increased mortality?
abstract: OBJECTIVE
  Examine the mediating effect of injectable drugs in the relationship between dialysis facility organizational status and patient mortality.
  
  
  METHODS
  Medicare dialysis population.
  
  
  METHODS
  Data from the U.S. Renal Data System (USRDS) were used to identify 3,884 freestanding dialysis facilities and 37,942 Medicare patients incident to end-stage renal disease (ESRD) in 2006. The role of injectable medications was evaluated during a 2-year follow-up period by mediational analyses using mixed-effect regression models.
  
  
  METHODS
  USRDS data were matched with Dialysis Facility Report data from Centers for Medicare and Medicaid Services (CMS) and census data.
  
  
  RESULTS
  There was a strong association found between organizational status and use of injectable drugs. Large for-profit chains used significantly higher injectable medications compared with nonprofit chains and independent facilities. However, the relationship between facility organizational status and patient mortality was not found to be mediated through the higher use of injectable drugs.
  
  
  CONCLUSIONS
  Large for-profit chain facilities administered higher IV epoetin, iron, and vitamin D dosages, but this did not result in improved survival. Given the associated costs and lack of a survival benefit, the overuse of injectable medications among the U.S. dialysis patients will likely end under the recent bundling of injectable medications without jeopardizing patient outcomes.
authors.affiliation: Medical Technology and Practice Patterns Institute, Bethesda, MD 20814, USA.
authors.forename: Yi
authors.initials: Y
authors.lastname: Zhang
authors.forename: Mae
authors.initials: M
authors.lastname: Thamer
authors.forename: Onkar
authors.initials: O
authors.lastname: Kshirsagar
authors.forename: Dennis J
authors.initials: DJ
authors.lastname: Cotter
mesh_terms: D000368:Aged; D000554:Ambulatory Care Facilities / Q000458:organization & administration* / Q000706:statistics & numerical data*; D015897:Comorbidity; D005260:Female; D015438:Health Behavior; D006302:Health Services Research; D006801:Humans; D007267:Injections / Q000706:statistics & numerical data*; D007676:Kidney Failure, Chronic / Q000188:drug therapy* / Q000401:mortality* / Q000628:therapy; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D008875:Middle Aged; D010067:Ownership / Q000458:organization & administration / Q000706:statistics & numerical data; D006435:Renal Dialysis / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D014481:United States