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Profit and haemodialysis

Review
Results
Comment

Bandolier 102 examined an intriguing review from North America looking at the profit motive on healthcare and mortality. It concluded that there was a higher risk of death in for-profit than in not-for-profit hospitals. A new review of haemodialysis centres comes to the same conclusion [1].

Review

The review is part of a larger study exploring the effects of the profit motive in healthcare. A complex search strategy examined 11 databases for studies examining mortality in haemodialysis patients in private centres run for profit, and private centres not run for profit. Both observational and randomised studies were looked for. Mortality, types of patients, and adjustment for potential confounding criteria were among information extracted from the studies.

Results

Seven publications reported eight observational studies, with 12 more that required additional information from authors but might eventually be eligible. The eight included studies had more than 500,000 patient years of information, with a follow up for individual patients between seven months and three to six years. All but one of the studies collected data in the 1990s, while the other collected data from 1973 to 1982.

Six of the eight studies, including the five largest studies, showed a statistically significant increase in mortality in for-profit haemodialysis centres (Figure 1). The only study with a point estimate of the relative risk in favour of for-profit centres was a small study performed over 20 years ago. The overall relative risk of death associated with for-profit haemodialysis centres was 1.09 (1.05 to 1.12).

Figure 1: Profit and mortality in haemodialysis centres (ranked by number of patients studied)



Comment

The potential impact of this finding on the United Sates was significant. Using a conservative estimate that 20% receiving haemodialysis care die every year, and that 75% receive care in private for-profit centres, the authors estimate that 2,500 fewer lives would be lost (95% confidence interval 1,200 to 4,000) if private not-for-profit centres were used.

Perhaps the larger point is that if the funding is relatively fixed, then profit means running a system with less resource, especially the number and quality of the human resource. It doesn't work.

Reference:

  1. PJ Devereaux et al. Comparison of mortality between private for-profit and private not-for-profit hemodialysis centers. A systematic review and meta-analysis. JAMA 2002 288: 2449-2457.
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