Effect of the ownership of dialysis facilities on patients' survival and referral for transplantation

N Engl J Med. 1999 Nov 25;341(22):1653-60. doi: 10.1056/NEJM199911253412205.


Background: More than 200,000 patients with end-stage renal disease undergo dialysis in the United States each year, about two thirds in for-profit centers. Economic pressures, such as the decline in inflation-adjusted Medicare payments for dialysis, may compromise the quality of care. Facilities may also be reluctant to refer patients to be evaluated for transplantation because of the loss of revenues from dialysis after patients receive transplants. It is unknown whether for-profit facilities respond more aggressively than not-for-profit facilities to these financial pressures. Therefore, we examined the effect of for-profit ownership of dialysis facilities on patients' survival and referral for possible transplantation.

Methods: We used data from the U.S. Renal Data System to assemble a nationally representative cohort of patients with end-stage renal disease of recent onset. We followed patients for a minimum of three years and a maximum of six years, until death, placement on the waiting list for a renal transplant, or loss to follow-up, or until May 31, 1996. We used proportional-hazards models to assess the effect of the profit status of the dialysis facility on patients' outcomes and adjusted for differences in sociodemographic, clinical, and facility-level characteristics.

Results: Of the 3681 patients who were eligible for inclusion, we included 3569 in the analysis of mortality and 3441 in the analysis of the waiting list. The crude mortality rate per 100 person-years of end-stage renal disease was 21.2 for patients treated in for-profit facilities and 17.1 for patients treated in not-for-profit centers (adjusted relative hazard, 1.20; 95 percent confidence interval, 1.02 to 1.42). The likelihood of being placed on the waiting list for a renal transplant was lower for patients treated at for-profit centers (adjusted relative hazard, 0.74; 95 percent confidence interval, 0.56 to 0.98).

Conclusions: In the United States, for-profit ownership of dialysis facilities, as compared with not-for-profit ownership, is associated with increased mortality and decreased rates of placement on the waiting list for a renal transplant.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Aged
  • Ambulatory Care Facilities / economics
  • Ambulatory Care Facilities / organization & administration*
  • Cohort Studies
  • Female
  • Health Facilities, Proprietary / economics
  • Health Facilities, Proprietary / organization & administration*
  • Humans
  • Kidney Failure, Chronic / mortality
  • Kidney Failure, Chronic / therapy*
  • Kidney Transplantation / economics
  • Kidney Transplantation / statistics & numerical data*
  • Male
  • Middle Aged
  • Ownership* / statistics & numerical data
  • Referral and Consultation / economics
  • Referral and Consultation / statistics & numerical data*
  • Regional Medical Programs
  • Registries
  • Renal Dialysis / economics*
  • Survival Rate
  • United States / epidemiology
  • Waiting Lists