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Death rate higher with for-profit dialysis

Kidney dialysis centers run for profit have an 8 percent higher death rate among patients than do nonprofit facilities, a new study shows.

But three-quarters of the more than 200,000 Americans who need to regularly have waste filtered from their blood with the procedure do so at private, for-profit centers.

"The source of the money for this care is the same _ virtually all of these services are paid for by Medicare _ and the patients are the same, so it appears the only difference is that some of these facilities have to spend 10 to 15 percent of their income, on average, to return a profit to investors and pay taxes," said Dr. Gordon Guyatt, a researcher at McMaster University in Ontario and a co-author of the study, published today in the Journal of the American Medical Association.

"Unfortunately, this translates into the premature death of 2,500 people a year that could be avoided if the same level of care was given at for-profit as nonprofit," Guyatt said.

The researchers looked at eight studies going back to 1973 and as recently as 1997 to follow the experiences of patients in the two types of facility. All but one found that nonprofit centers had lower death rates.

While most of the studies used administrative rather than clinical records, Guyatt said the one study that used information taken directly from patient charts showed the most significant difference.

"We only included studies that took into account why people were on dialysis, their age and sex and other health differences, so we're sure there's no bias on who's using the different centers," he said. "If we're off at all, it's an underestimate of the mortality."

The researchers argue that for-profit centers have more incentive to cut corners: to hire fewer staffers, to hire workers with less training (fewer registered nurses in favor of nurse's aides and technicians), to keep patients on dialysis for shorter times at each session or use fewer drugs in therapy.

"Seventy percent of the costs of these centers is people, and if there are fewer, less well-trained people spending less time with the patients, it all may make an impact," Guyatt said.

He explained that the study was of particular concern to Canadian researchers, even though all dialysis in Canada is now done at private, nonprofit centers affiliated with hospitals.

"There's a movement to change the health care system to use public funding to pay for-profit centers as well, and we wanted to understand the implications of that," Guyatt said.

Dr. Sidney Wolfe, director of the Public Citizen Health Research Group in Washington, host of a news conference for Guyatt on Tuesday, said the current system underscores the difficulty of ensuring quality from private health providers even when the federal government foots virtually the entire tab.

"Medicare has tremendous leverage over the quality of these services for patients with end-stage kidney disease. It needs to set more standards, and it's unfortunate that it hasn't," Wolfe said.