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:
- 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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