The effect of dialysis chains on mortality in patients receiving hemodialysis
Open AccessSubstantial survival differences have been found across the nation's roughly 4,000 Medicare-certified dialysis facilities where patients with end stage renal disease (ESRD) routinely receive hemodialysis. During the past fifteen years, the tremendous growth and consolidation of large dialysis chains have raised concerns about the quality of care delivered to ESRD patients. However, little is known regarding whether there are differences in patient outcomes between patients receiving dialysis care from facilities affiliated with chains versus nonchain facilities. Furthermore, it has been previously speculated that practice patterns, especially the overuse of separately billable injectable drugs might explain the higher mortality found in certain dialysis providers. Accordingly, this dissertation examined 1) whether patients treated in dialysis chain facilities have better or worse survival after adjusting for other facility characteristics and a wide range of patient characteristics and 2) whether the relationship between dialysis chain status and patient mortality might be mediated through providers' economically driven practices, such as the potential overuse of injectable drugs. By using data from the United States Renal Data System (USRDS) and applying multilevel regression models, this study found evidence that chain status of dialysis facilities was independently related to patient mortality. In addition, there was a strong association between chain status and use of injectable drugs. However, the relationship between chain status and patient mortality was not found to be mediated through the use of injectable drugs. Policy implications of these results are related to the forthcoming bundled-payment system, an effort to reduce the doses and cost of injectable drugs. Given doses of injectable drugs were not found to be associated with patient mortality, patient outcomes might not be compromised by bundling injectable drugs into the composite rate.
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