1023 Renal care in private vs public dialysis facilities

The current debate in South Africa around implementation of a National Health Insurance plan is premised on the current imbalance between Rands per patient spent in the two sectors (private and public) and the differences in access to care. There is an assumption that quality of care is invariably also poorer in the public sector, but there is little formal, scientific research to back that up. Disparities in care have been studied and continue to be studied in various parts of the world, looking at private vs public, male vs female, white vs black, indigenous vs immigrant populations etc, and in a recent article from Stanford and Yale Universities the focus was once again on outcomes in patients dialysed for renal failure. Looking at number of hospital days per patient per year for Medicare patients treated in for-profit vs non-profit facilities, the authors found that overall, after adjustment for patient and facility factors, patients who received in-centre dialysis in for-profit facilities had 17.5±5% more hospital days per year. They also found that larger and busier facilities (with >70 patients) had a 14±1.7% increase in hospital days vs those with <35 patients. This translated to a potential for a reduction of 1600 patient years per annum if hospital utilization rates for for-profit facilities were to decrease to the level of their non-profit counterparts. The authors concluded that the Medicare payment system to for-profit facilities provided insufficient incentives to achieve optimal patient outcomes. Exactly what that means in terms of clinical care is uncertain, but one cannot automatically conclude that it implies under-treatment because previous research has also shown that private, for-profit dialysis facilities in the US over-treated patients in terms of administration of erythropoietin, with the drug being a driver of cost and profit. So, additional hospital days may be the result of either too little or too much care, but the exact basis in the Stanford-Yale study is not clear given that the erythropoietin issue arose around 2007 while the Stanford-Yale study focused on 2003 Medicare patient data (see summaries 702, 707). Other authors have addressed the problem from a paediatric perspective, in 1999 finding that for-profit facilities were 2-3 times more likely to use peritoneal vs haemodialysis than those that were nonprofit. Issues of this nature are crying out to be formally studied in South Africa.

Read more:
Health Serv Res 2010; 45: 633-46
JAMA 2007; 297: 1713-6
Pediatrics 1999; 104: 519-24