April 6, 2000 - Today's issue of the New England Journal of Medicine provides six responses (letters to the editor) that comment on articles by Garg et al. (Nov. 25 issue) that reported on the effect of the ownership of dialysis facilities on patients' survival and referral for transplantation.

Five letters question the study design and provide criticisms of the conclusions reached by Garg et al. The final letter is from Garg and fellow authors and contains their responses to these questions and criticisms. One letter is a joint statement by medical directors from Fresenius Medical Care, Gambro Healthcare, and Total Renal Care.

In their original articles, Garg et al. claimed that for-profit dialysis centers have a 20% higher mortality rate and were 26% less likely to refer patients for transplantation as compared to non-profit units. One letter offers evidence that these rates are not as drastic as Garg et al. state. Instead, their data shows that for-profit centers have a mortality rate that is 6% higher and they are 15% less likely to refer patients for transplantation.

December 1, 1999 - The national newspaper headlines currently read

"Kidney Transplant Cuts Death Rate by 82 Percent"

This story came from the December 2nd issue of New England Journal of Medicine (NEJM) which includes a study (view abstract) that shows that patients who receive kidney transplants live 10 years longer than those who remain on waiting lists.

November 27 - Debate continues about the conclusions of the studies published in the New England Journal of Medicine about survival rates and transplant referral rates in for-profit dialysis centers vs. non-profits. Not all agree that these studies tell the whole truth and many point to complex issues not addressed by the studies. For example, expect to see the argument made that the for-profit centers have older, sicker patients.

Comments by National Renal Administrator Association (NRAA) President Terry Bahr can be found in this Associated Press story. For another analysis, here is the New York Times version.

Top three for-profit dialysis companies: Fresenius reports 78,500 patients in 1070 dialysis centers. Total Renal Care now has 45,000 patients in 569 dialysis centers. Gambro reports 43,200 patients in 581 dialysis centers.

November 24 - The national newspaper headlines currently read

"Death Rates Higher at U.S. For-Profit Dialysis Units"

This is because the November 25th issue of New England Journal of Medicine (NEJM) includes a study that compares the survival rates and transplant rates of for-profit and non-profit dialysis centers.

The NEJM provides the abstract (summary) of the study on its web site. Full text reprints of the studies can be purchased on the NEJM web site.

View Study #1 Abstract: Effect of the Ownership of Dialysis Facilities on Patients' Survival and Referral for Transplantation. (Latest data used was May 31, 1996.)

"Conclusions: In the United States, for-profit ownership of dialysis facilities, as compared with not-for-profit ownership, is associated with increased mortality and decreased rates of placement on the waiting list for a renal transplant. (N Engl J Med 1999;341:1653-60.)"

The National Kidney Foundation has published its response to the mortality study on its web site.

You can hear the story with analysis and commentary on National Public Radio's All Things Considered. (Real AudioPlayer� is required.)


This issue of the NEJM also includes an article about racial differences in access to kidney transplantation. The NEJM issue also included an editorial on the topic.

View Study #2 Abstract: The Effect of Patients' Preferences on Racial Differences in Access to Renal Transplantation. (Latest data used was March 1999.)

"Conclusions: In the United States, the preferences and expectations with respect to renal transplantation among patients with end-stage renal disease differ according to race. These differences, however, explain only a small fraction of the substantial racial differences in access to transplantation. Physicians should ensure that black patients who desire renal transplantation are fully informed about it and are referred for evaluation. (N Engl J Med 1999;341:1661-9.)"

View NEJM Editorial: Quality and Equity in Dialysis and Renal Transplantation

In response to these studies, The Health Care Financing Administration (HCFA) announced today that the Medicare program is taking new steps to ensure that all patients with renal failure, regardless of race or ethnicity, are being evaluated for kidney transplantation.

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[This message has been edited by Gary Peterson (edited 07-09-2001).]

I have only read the abstract of the paper titled "Effect of the Ownership of Dialysis Facilities on Patients'Survival and Referral for Transplantation" by Pushkal P. Garg, Kevin D. Frick, Marie Diener-West, Neil R. Powe. I believe it raises a legitimate concern, but it doesn't identify the most crucial factors in delivering high quality care of dialysis patients. It is unfortunate too, there is probably no scientific way to prove it.

To me, the most important factors in delivering high quality care for dialysis patients are PEOPLE, PEOPLE, PEOPLE. Given identical clinical guidelines, the care that experienced, knowledgeable, and continuously learning staff provides will always result in better outcomes than the care provided by inexperienced staff and unmotivated staff.

Do for-profit centers create an environment where long-term, knowledgeable, and motivated employees are valued? Are non-profit dialysis centers more likely to provide and encourage educational opportunities for their staff than for-profit centers? I think it's time to look at Human Resources policies, rather than clinical protocols.

Can you teach inexperienced staff to deliver a target URR once a month? With sufficient threats and punishment, anyone can be taught NOT to cut short or underdeliver the one dialysis treatment per month when the URR is actually measured. But what of the other twelve treatments each month? How often is the full treatment actually delivered when the URR isn't being measured? What motivates the inexperienced staff then? Can you imagine the effects that staff experience and knowledge has on other complications such as infection rates and damaged grafts? People, it's PEOPLE, PEOPLE, PEOPLE.

I agree. The problems are most often staff related. My mother is a dialysis patient and there are some staff memebers that take excellent care of her and others who do what they have to do to get through the treatment. I have seen alarms go unanswered, or monitor lines be clamped off because the alarm was going off too much !
Patients know who the good staff are. They ask for them. They also know who the ones who don't care are. They avoid them if they can. Then there are those patients who use the staff's poor judgement and apathy to their "advantage" by asking to come off early. Some staff don't think twice about taking patients off before their treatement time is up. I have seen medications missed but charted as if they have been given, blood pressures not taken but written down as if they had been. It's criminal !
The people who wrote that article in the NEJM should go spend some time in a dialysis unit. I don't think it matters if it's for profit or not. Good care is good care and it takes quality staff to provide good care.
Like you said, it comes down to the people that provide the care. Are they knowledgable about the therapy they are providing ? Do they care about the patients ? Are they constantly learning and growing ? Is it just a job to them ? If so they should get a job somewhere else.

I believe that For-Profit dialysis has done great harm to quality patient care! Many great dialysis nurses have left the field because of their disgust at what is happening to the industry. It use to be that knowledgable/skillfull nurses and PCT's were valued over turnover, but now, that is all the companies are concerned with. Large corporations are so concerned with making the day as short as possible with as little staff as possible, that they allow for no patient education, QA Teams to form, or adequate training for new staff. Dialysis units have turned into sweatshops full of undertrained, miserable staff members. It is time for action, I think.
I loved dialysis until a large corporation took us over. It became a miserable environment.

While I would agree with Mary's comment that quality of care equates less with a programs status (profit or not-for profit) but more with its personal. You have to look at the foundation that the program is built upon.

I have spent a large part of my professional life working in this field and the personal decision I have made is to only be associated with an organization that places patients first and foremost. Its been my own experience that the for-profits have not established this same benchmark.

The for-profits bottom line is profit and while a reasonible person could agrue that
quality outcomes should increase profits, in practice, cost cutting in these environments usually comes at the expense of quality. I am almost at the point of leaving this field over the direction its been heading.

The question I continue to ask myself is when the financial incentives that pulls these corporations into this area no longer present or the cost of doing business becomes too high...who will be left in the wake? I fell in love with this field the moment I walked into a dialysis unit and refuse to walk away at what will be seen as its darkest days...just not sure I will continue to have the strength to continue on.