In the Journals

Improvements in care slows for patients once treated at clinics acquired by large dialysis providers

Kevin Erickson

A study that examined the influence of dialysis clinic ownership on patient outcomes in the United States found improvements in care slowed once independently owned clinics were acquired.

“Acquisition of independently owned dialysis facilities by larger dialysis organizations was associated with slower decreases in mortality and hospitalization rates, as nonacquired facilities appeared to experience more rapid improvements in outcomes over time,” Kevin Erickson, MD, MS, from Baylor School of Medicine, and colleagues wrote in their paper.

The researchers directed a cohort study using difference-in-differences (DID) analyses to look at changes in health outcomes over time among in-center dialysis facilities that were acquired by a hemodialysis chain with facilities located nearby but not acquired. In addition to examining all acquisitions together, they also separately analyzed acquisitions of independent and chain facilities. The primary outcomes for the two treatment facility types were the risk of death over the first 12 months of dialysis and hospital days per patient year.

Data were collected from January 2001 to September 2015 on 174,905 patients who started in-center dialysis in the 3 years before and following dialysis facility acquisitions. Data were analyzed from March 2017 to December 2018, and the review and comparisons accounted for patient, facility and geographic characteristics.

Of the patients included in the study, 79,705 were women (45.6%); 24,409 (14%) were of Hispanic ethnicity; 61,815 (35.3%) were black; 105,272 (60.2%) were white and 1,247 (0.7%) were Native American. The mean age was 65 years old, the authors said.

While improvements in care were seen for patients who were treated in either dialysis chains or an independent facility, improvements slowed at independent facilities once they were acquired.

Before acquisitions, mortality rates were lower at independent facilities that were acquired, while hospitalization rates were lower at both independent and chain-owned facilities that were acquired compared to those that were not acquired.

“In stratified analyses of independently owned facilities, mortality decreases were smaller at acquired (−8.4%; 95% CI,−14% to−25%) vs nonacquired (−20.3%; 95% CI,−25.8% to −14.3%) facilities (DIDP<.001). Similarly, hospitalization rates did not change at acquired facilities and decreased by 2.6 days per patient-year (95% CI,−3.6 to−1.7 days) at nonacquired facilities (DID P<.001). Acquisitions were not associated with changes in health outcomes at chain-owned facilities.”

In an invited commentary, Virginia Wang, PhD, and Matthew L. Maciejewski, PhD, discussed the changes in the dialysis industry during the past 2 decades, particularly the increase in the number of larger for-profit dialysis providers.

“Nonprofit, independently owned, and hospital-based facilities have been increasingly overtaken by freestanding, for-profit dialysis facilities affiliated with a smaller number of large dialysis organizations (LDOs),” they wrote.

Wang and Maciejewski said the study results “represent an important contribution to the literature because it suggests that not all consolidations are equal, since independent facilities improved the most of all nonacquired facilities. The good news is that outcomes for all patients are improving over time, regardless of acquisition status. The cautionary tale of this study is that outcome improvements were greater for patients seen in facilities that were not acquired. Although the specific reasons for these differences remain unclear, these findings raise concerns about whether patients realize significant benefits from consolidation in the dialysis industry.” –by Mark E. Neumann

Disclosures: Erickson serves as a paid consultant for Acumen LLC and reported grants from the National Institutes for Diabetes and Digestive and Kidney Diseases (NIDDK) during the conduct of the study and personal fees from Acumen LLC outside the submitted work. Please see the study for a full list of his disclosures.

Funding for the study was provided through grant K23 1K23DK101693-01 from the NIDDK. This material was also supported by the use of facilities and resources of the Houston Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety (grant CIN13-413). Wang and Maciejewski reported grant R01 DK097165 from the NIDDK and grants RCS 10-391 and CIN 13-410 and nonfinancial support from Department of Veterans Affairs during the conduct of the study. Maciejewski owns Amgen stock due to his spouse’s employment.

 

Kevin Erickson

A study that examined the influence of dialysis clinic ownership on patient outcomes in the United States found improvements in care slowed once independently owned clinics were acquired.

“Acquisition of independently owned dialysis facilities by larger dialysis organizations was associated with slower decreases in mortality and hospitalization rates, as nonacquired facilities appeared to experience more rapid improvements in outcomes over time,” Kevin Erickson, MD, MS, from Baylor School of Medicine, and colleagues wrote in their paper.

The researchers directed a cohort study using difference-in-differences (DID) analyses to look at changes in health outcomes over time among in-center dialysis facilities that were acquired by a hemodialysis chain with facilities located nearby but not acquired. In addition to examining all acquisitions together, they also separately analyzed acquisitions of independent and chain facilities. The primary outcomes for the two treatment facility types were the risk of death over the first 12 months of dialysis and hospital days per patient year.

Data were collected from January 2001 to September 2015 on 174,905 patients who started in-center dialysis in the 3 years before and following dialysis facility acquisitions. Data were analyzed from March 2017 to December 2018, and the review and comparisons accounted for patient, facility and geographic characteristics.

Of the patients included in the study, 79,705 were women (45.6%); 24,409 (14%) were of Hispanic ethnicity; 61,815 (35.3%) were black; 105,272 (60.2%) were white and 1,247 (0.7%) were Native American. The mean age was 65 years old, the authors said.

While improvements in care were seen for patients who were treated in either dialysis chains or an independent facility, improvements slowed at independent facilities once they were acquired.

Before acquisitions, mortality rates were lower at independent facilities that were acquired, while hospitalization rates were lower at both independent and chain-owned facilities that were acquired compared to those that were not acquired.

“In stratified analyses of independently owned facilities, mortality decreases were smaller at acquired (−8.4%; 95% CI,−14% to−25%) vs nonacquired (−20.3%; 95% CI,−25.8% to −14.3%) facilities (DIDP<.001). Similarly, hospitalization rates did not change at acquired facilities and decreased by 2.6 days per patient-year (95% CI,−3.6 to−1.7 days) at nonacquired facilities (DID P<.001). Acquisitions were not associated with changes in health outcomes at chain-owned facilities.”

In an invited commentary, Virginia Wang, PhD, and Matthew L. Maciejewski, PhD, discussed the changes in the dialysis industry during the past 2 decades, particularly the increase in the number of larger for-profit dialysis providers.

“Nonprofit, independently owned, and hospital-based facilities have been increasingly overtaken by freestanding, for-profit dialysis facilities affiliated with a smaller number of large dialysis organizations (LDOs),” they wrote.

Wang and Maciejewski said the study results “represent an important contribution to the literature because it suggests that not all consolidations are equal, since independent facilities improved the most of all nonacquired facilities. The good news is that outcomes for all patients are improving over time, regardless of acquisition status. The cautionary tale of this study is that outcome improvements were greater for patients seen in facilities that were not acquired. Although the specific reasons for these differences remain unclear, these findings raise concerns about whether patients realize significant benefits from consolidation in the dialysis industry.” –by Mark E. Neumann

Disclosures: Erickson serves as a paid consultant for Acumen LLC and reported grants from the National Institutes for Diabetes and Digestive and Kidney Diseases (NIDDK) during the conduct of the study and personal fees from Acumen LLC outside the submitted work. Please see the study for a full list of his disclosures.

Funding for the study was provided through grant K23 1K23DK101693-01 from the NIDDK. This material was also supported by the use of facilities and resources of the Houston Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety (grant CIN13-413). Wang and Maciejewski reported grant R01 DK097165 from the NIDDK and grants RCS 10-391 and CIN 13-410 and nonfinancial support from Department of Veterans Affairs during the conduct of the study. Maciejewski owns Amgen stock due to his spouse’s employment.