Hemodialysis system privatization and patient survival: a report from a large registry Eastern Europe cohort

Background: There has been a rapid increase in incident and prevalent rates of hemodialysis (HD) patients in Romania following the 2004 system privatization, but little is known about the impact of privatization on patient outcomes. Methods: We retrospectively examined the outcome during 1 year of 8161 prevalent HD patients registered in the Romanian Renal Registry at 31 December 2011. Standardized mortality ratio (SMR) was calculated for each for-profit (FP) and non-profit (NP) HD provider. Results: The 12-month SMR across all HD chain providers was 1.27. FP Chain 1 and the other group had SMR similar to the reference level. The mortality rate was two times higher in public NP dialysis centers than the national reference. A stepwise Cox regression analysis identified older age, male gender, DN as primary renal disease and the HD chain provider to be independently associated with a higher mortality. Excepting patients treated by FP Chain 4, patients treated by all the other dialysis providers had a better outcome than those treated in NP facilities. Conclusion: In conclusion, the increase in number of patients treated was not doubled by an increase in their survival. In the context of an expanding dialysis marketplace that tends to consolidate around large for-profit (FP) providers, further exploration of indicators associated with mortality may guide future healthcare policy to improve patient outcomes.