Brunelli Steven M, Wilson Steven, Krishnan Mahesh, Nissenson Allen R
DaVita Clinical Research, 825 South 8th Street, Suite 300, Minneapolis, Minnesota 55404, USA.
BMC Nephrol. 2014 Jul 21;15:121. doi: 10.1186/1471-2369-15-121.
Patient outcomes have been compared on the basis of the profit status of the dialysis provider (for-profit [FP] and not-for-profit [NFP]). In its annual report, United States Renal Data System (USRDS) provides dialysis provider level death and hospitalization rates adjusted by age, race, sex, and dialysis vintage; however, recent analyses have suggested that other variables impact these outcomes. Our current analysis of hospitalization and mortality rates of hemodialysis patients included adjustments for those used by the USRDS plus other potential confounders: facility geography (end-stage renal disease network), length of facility ownership, vascular access at first dialysis session, and pre-dialysis nephrology care.
We performed a provider level, retrospective analysis of 2010 hospitalization and mortality rates among US hemodialysis patients exclusively using USRDS sources. Crude and adjusted incidence rate ratios (IRRs) were calculated using the 4 standard USRDS patient factors plus the 4 potential confounders noted above.
The analysis included 366,011 and 34,029 patients treated at FP and NFP facilities, respectively. There were statistical differences between the cohorts in geography, facility length of ownership, vascular access, and pre-dialysis nephrology care (p < 0.001), as well as age (p < 0.01), race (p < 0.001), and vintage (p < 0.001), but not sex (p = 0.12). When using standard USRDS adjustments, hospitalization and mortality rates for FP and NFP facilities were most disparate, favoring the NFP facilities. Rates were most similar between providers when adjustments were made for each of the 8 factors. With the FP IRR as the referent (1.0), the hospitalization IRR for NFP facilities was 1.00 (95% confidence interval [CI] 0.97-1.02; p = 0.69), while the NFP mortality IRR was 1.01 (95% CI 0.97-1.05; p = 0.64).
These data suggest there is no difference in mortality and hospitalization rates between FP and NFP dialysis clinics when appropriate statistical adjustments are made.
已根据透析服务提供商的盈利状况（营利性[FP]和非营利性[NFP]）对患者预后进行了比较。在美国肾脏数据系统（USRDS）的年度报告中，提供了按年龄、种族、性别和透析龄调整后的透析服务提供商层面的死亡率和住院率；然而，最近的分析表明，其他变量会影响这些预后。我们目前对血液透析患者住院率和死亡率的分析纳入了USRDS所使用的那些调整因素以及其他潜在混杂因素：机构地理位置（终末期肾病网络）、机构所有权时长、首次透析时的血管通路以及透析前的肾病护理。
我们仅使用USRDS来源对美国血液透析患者2010年的住院率和死亡率进行了机构层面的回顾性分析。使用USRDS的4个标准患者因素以及上述4个潜在混杂因素计算粗发病率比（IRR）和调整后的发病率比。
该分析分别纳入了在营利性和非营利性机构接受治疗的366,011例和34,029例患者。队列之间在地理位置、机构所有权时长、血管通路和透析前肾病护理方面存在统计学差异（p<0.001），在年龄（p<0.01）、种族（p<0.001）和透析龄（p<0.001）方面也存在差异，但在性别方面无差异（p=0.12）。使用USRDS的标准调整时，营利性和非营利性机构的住院率和死亡率差异最大，非营利性机构更具优势。对8个因素中的每一个进行调整后，各机构之间的比率最为相似。以营利性机构的IRR作为参照（1.0），非营利性机构的住院IRR为1.00（95%置信区间[CI]0.97 - 1.02；p=0.69），而非营利性机构的死亡IRR为1.01（95%CI 0.97 - 1.05；p=0.64）。
这些数据表明，进行适当的统计调整后，营利性和非营利性透析诊所的死亡率和住院率没有差异。
