November 20, 2002

Comparison of Mortality Between Private For-Profit and Private Not-For-Profit Hemodialysis CentersA Systematic Review and Meta-analysis

Author Affiliations

Author Affiliations: Departments of Medicine (Drs Devereaux, Cook, and Guyatt), Surgery (Dr Bhandari), Anesthesia (Dr Choi), Clinical Epidemiology and Biostatistics (Drs Choi, Haines, Lavis, Cook, and Guyatt, Ms Lacchetti, and Mr Weaver), and Psychiatry and Behavioral Neurosciences (Dr Haslam), McMaster University, Hamilton, Ontario; Departments of Medicine (Drs Schünemann and Grant), Physiology and Biophysics (Dr Grant), and Social and Preventive Medicine (Drs Schünemann and Grant), University at Buffalo, and Veterans Affairs Medical Center (Dr Grant), Buffalo, NY; Faculty of Medicine (Ms Ravindran) and Department of Health Policy Management and Evaluation (Dr Sullivan), University of Toronto, and Institute for Work and Health and Population Health Program, Canadian Institute for Advanced Research (Dr Lavis), Toronto, Ontario; and Division of Nephrology, University of Western Ontario, London (Dr Garg).

JAMA. 2002;288(19):2449-2457. doi:10.1001/jama.288.19.2449

Context Private for-profit and private not-for-profit dialysis facilities provide the majority of hemodialysis care in the United States. There has been extensive debate about whether the profit status of these facilities influences patient mortality.

Objective To determine whether a difference in adjusted mortality rates exists between hemodialysis patients receiving care in private for-profit vs private not-for-profit dialysis centers.

Data Sources We searched 11 bibliographic databases, reviewed our own files, and contacted experts in June 2001–January 2002. In June 2002, we also searched PubMed using the "related articles" feature, SciSearch, and the reference lists of all studies that fulfilled our eligibility criteria.

Study Selection We included published and unpublished observational studies that directly compared the mortality rates of hemodialysis patients in private for-profit and private not-for-profit dialysis centers and provided adjusted mortality rates. We masked the study results prior to determining study eligibility, and teams of 2 reviewers independently evaluated the eligibility of all studies. Eight observational studies that included more than 500 000 patient-years of data fulfilled our eligibility criteria.

Data Extraction Teams of 2 reviewers independently abstracted data on study characteristics, sampling method, data sources, and factors controlled for in the analyses. Reviewers resolved disagreements by consensus.

Data Synthesis The studies reported data from January 1, 1973, through December 31, 1997, and included a median of 1342 facilities per study. Six of the 8 studies showed a statistically significant increase in adjusted mortality in for-profit facilities, 1 showed a nonsignificant trend toward increased mortality in for-profit facilities, and 1 showed a nonsignificant trend toward decreased mortality in for-profit facilities. The pooled estimate, using a random-effects model, demonstrated that private for-profit dialysis centers were associated with an increased risk of death (relative risk, 1.08; 95% confidence interval, 1.04-1.13; P<.001). This relative risk suggests that there are annually 2500 (with a plausible range of 1200-4000) excessive premature deaths in US for-profit dialysis centers.

Conclusions Hemodialysis care in private not-for-profit centers is associated with a lower risk of mortality compared with care in private for-profit centers.