Division of Nephrology, Department of Medicine and Pediatrics, University of California, San Francisco, San Francisco.
Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco.
JAMA Pediatr. 2023 Oct 1;177(10):1065-1072. doi: 10.1001/jamapediatrics.2023.3414.
In adults, treatment at profit dialysis facilities has been associated with a higher risk of death.
To determine whether profit status of dialysis facilities is associated with the risk of death in children with kidney failure treated with dialysis and whether any such association is mediated by differences in access to transplant.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study reviewed US Renal Data System records of 15 359 children who began receiving dialysis for kidney failure between January 1, 2000, and December 31, 2019, in US dialysis facilities. The data analysis was performed between May 2, 2022, and June 15, 2023.
Time-updated profit status of dialysis facilities.
Adjusted Fine-Gray models were used to determine the association of time-updated profit status of dialysis facilities with risk of death, treating kidney transplant as a competing risk. Cox proportional hazards regression models were also used to determine time-updated profit status with risk of death regardless of transplant status.
The final cohort included 8465 boys (55.3%) and 6832 girls (44.7%) (median [IQR] age, 12 [3-15] years). During a median follow-up of 1.4 (IQR, 0.6-2.7) years, with censoring at transplant, the incidence of death was higher at profit vs nonprofit facilities (7.03 vs 4.06 per 100 person-years, respectively). Children treated at profit facilities had a 2.07-fold (95% CI, 1.83-2.35) higher risk of death compared with children at nonprofit facilities in adjusted analyses accounting for the competing risk of transplant. When follow-up was extended regardless of transplant status, the risk of death remained higher for children treated in profit facilities (hazard ratio, 1.47; 95% CI, 1.35-1.61). Lower access to transplant in profit facilities mediated 67% of the association between facility profit status and risk of death (95% CI, 45%-100%).
Given the higher risk of death associated with profit dialysis facilities that is partially mediated by lower access to transplant, the study's findings indicate a need to identify root causes and targeted interventions that can improve mortality outcomes for children treated in these facilities.
在成年人中，在盈利透析机构接受治疗与死亡风险增加有关。
确定营利性透析机构的盈利状况是否与接受透析治疗的肾衰竭儿童的死亡风险相关，以及这种关联是否由移植机会的差异所介导。
设计、地点和参与者：这项回顾性队列研究在美国肾脏数据系统中回顾了 15359 名儿童的记录，这些儿童在 2000 年 1 月 1 日至 2019 年 12 月 31 日期间在美国透析机构开始接受透析治疗以治疗肾衰竭。数据分析于 2022 年 5 月 2 日至 2023 年 6 月 15 日进行。
透析机构的时间更新的盈利状况。
使用调整后的 Fine-Gray 模型来确定透析机构的时间更新的盈利状况与死亡风险之间的关联，将肾移植作为竞争风险。还使用 Cox 比例风险回归模型来确定无论移植状况如何，时间更新的盈利状况与死亡风险之间的关联。
最终队列包括 8465 名男孩（55.3%）和 6832 名女孩（44.7%）（中位数[IQR]年龄，12[3-15]岁）。在中位数为 1.4（IQR，0.6-2.7）年的中位随访期间，以移植为截尾，营利性与非营利性机构的死亡率更高（分别为每 100 人年 7.03 例和 4.06 例）。在调整了移植竞争风险的分析中，与非营利性机构相比，营利性机构治疗的儿童死亡风险高 2.07 倍（95%CI，1.83-2.35）。当随访时间延长而不考虑移植状态时，营利性机构治疗的儿童的死亡风险仍然更高（风险比，1.47；95%CI，1.35-1.61）。营利性机构较低的移植机会部分介导了设施盈利状况与死亡风险之间 67%的关联（95%CI，45%-100%）。
鉴于与盈利性透析机构相关的死亡风险较高，部分原因是移植机会较低，因此，该研究结果表明，需要确定根本原因和有针对性的干预措施，以改善在这些机构接受治疗的儿童的死亡率。
