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Association Between Dialysis Facility Ownership and Mortality Risk in Children With Kidney Failure
Elaine Ku1,2, Charles E McCulloch2, Alexandra Bicki1
1Division of Nephrology, Department of Medicine and Pediatrics, University of California, San Francisco, San Francisco.
Insights
Children undergoing dialysis at for-profit facilities face a higher mortality risk compared to nonprofit facilities. This increased risk is partly due to reduced access to kidney transplants.
Area of Science:
- Pediatric Nephrology
- Health Services Research
- Epidemiology
Background:
- For-profit dialysis facilities in adults are linked to increased mortality.
- Understanding this association in pediatric populations is crucial for improving care.
Purpose of the Study:
- To investigate the association between for-profit dialysis facility status and mortality risk in children with kidney failure.
- To examine if transplant access mediates this association.
Main Methods:
- Retrospective cohort study using US Renal Data System records (2000-2019).
- Analysis of 15,359 children initiating dialysis.
- Time-updated profit status and competing risks (transplant) were analyzed using Fine-Gray and Cox regression models.
Main Results:
- Children at for-profit facilities had a 2.07-fold higher risk of death (95% CI, 1.83-2.35) compared to nonprofit facilities.
- This risk remained elevated (HR, 1.47; 95% CI, 1.35-1.61) when transplant was not censored.
- Reduced transplant access at for-profit facilities mediated 67% of the increased mortality risk.
Conclusions:
- For-profit dialysis facility status is associated with significantly higher mortality in children with kidney failure.
- Lower transplant access in these facilities is a key factor mediating this disparity.
- Targeted interventions are needed to address disparities and improve outcomes in pediatric dialysis care.
Importance:
In adults, treatment at profit dialysis facilities has been associated with a higher risk of death.
Objective:
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.
Exposure:
Time-updated profit status of dialysis facilities.
Main Outcomes And Measures:
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.
Results:
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%).
Conclusions And Relevance:
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.
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