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).
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
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Study Selection We included published and unpublished observational studies that directly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.
Devereaux PJ, Schünemann HJ, Ravindran N, Bhandari M, Garg AX, Choi PT, Grant BJB, Haines T, Lacchetti C, Weaver B, Lavis JN, Cook DJ, Haslam DRS, Sullivan T, Guyatt GH. Comparison of Mortality Between Private For-Profit and Private Not-For-Profit Hemodialysis CentersA Systematic Review and Meta-analysis. JAMA. 2002;288(19):2449–2457. doi:10.1001/jama.288.19.2449
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