Association Between Dialysis Facility Ownership and Access to the Waiting List and Transplant in Pediatric Patients With End-stage Kidney Disease in the US

IMPORTANCE

Care of adults at profit vs nonprofit dialysis facilities has been associated with lower access to transplant. Whether profit status is associated with transplant access for pediatric patients with end-stage kidney disease is unknown.

OBJECTIVE

To determine whether profit status of dialysis facilities is associated with placement on the kidney transplant waiting list or receipt of kidney transplant among pediatric patients receiving maintenance dialysis.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study reviewed the US Renal Data System records of 13 333 patients younger than 18 years who started dialysis from 2000 through 2018 in US dialysis facilities (followed up through June 30, 2019).

EXPOSURES

Time-updated profit status of dialysis facilities.

MAIN OUTCOMES AND MEASURES

Cox models, adjusted for clinical and demographic factors, were used to examine time to wait-listing and receipt of kidney transplant by profit status of dialysis facilities.

RESULTS

A total of 13 333 pediatric patients who started receiving maintenance dialysis were included in the analysis (median age, 12 years [IQR, 3-15 years]; 6054 females [45%]; 3321 non-Hispanic Black patients [25%]; 3695 Hispanic patients [28%]). During a median follow-up of 0.87 years (IQR, 0.39-1.85 years), the incidence of wait-listing was lower at profit facilities than at nonprofit facilities, 36.2 vs 49.8 per 100 person-years, respectively (absolute risk difference, -13.6 (95% CI, -15.4 to -11.8 per 100 person-years; adjusted hazard ratio [HR] for wait-listing at profit vs nonprofit facilities, 0.79; 95% CI, 0.75-0.83). During a median follow-up of 1.52 years (IQR, 0.75-2.87 years), the incidence of kidney transplant (living or deceased donor) was also lower at profit facilities than at nonprofit facilities, 21.5 vs 31.3 per 100 person-years, respectively; absolute risk difference, -9.8 (95% CI, -10.9 to -8.6 per 100 person-years) adjusted HR for kidney transplant at profit vs nonprofit facilities, 0.71 (95% CI, 0.67-0.74).

CONCLUSIONS AND RELEVANCE

Among a cohort of pediatric patients receiving dialysis in the US from 2000 through 2018, profit facility status was associated with longer time to wait-listing and longer time to kidney transplant.

Treatment success for patients with tuberculosis receiving care in areas severely affected by Hurricane Matthew - Haiti, 2016

BACKGROUND

On October 4, 2016, Hurricane Matthew struck southwest Haiti as a category 4 storm. The goal of this study was to evaluate the impact of the hurricane on tuberculosis (TB) services and patient outcomes in the three severely affected departments-Sud, Grand'Anse, and Nippes-of southwest Haiti.

METHODS

We developed a standard questionnaire to assess a convenience sample of health facilities in the affected areas, a patient tracking form, and a line list for tracking all patients with drug-susceptible TB registered in care six months before the hurricane. We analyzed data from the national TB electronic surveillance system to determine outcomes for all patients receiving anti-TB treatment in the affected areas. We used logistic regression analysis to determine factors associated with treatment success.

RESULTS

Of the 66 health facilities in the three affected departments, we assessed 31, accounting for 536 (45.7%) of 1,174 TB patients registered in care when Hurricane Matthew made landfall in Haiti. Three (9.7%) health facilities sustained moderate to severe damage, whereas 18 (58.1%) were closed for <1 week, and five (16.1%) for ≥1 week. Four weeks after the hurricane, 398 (73.1%) of the 536 patients in the assessed facilities were located. Treatment success in the affected departments one year after the hurricane was 81.4%. Receiving care outside the municipality of residence (adjusted odds ratio [aOR]: 0.46, 95% confidence interval [CI]: 0.27-0.80) and HIV positivity (aOR: 0.31, 95% CI: 0.19-0.51) or unknown HIV status (aOR: 0.49, 95% CI: 0.33-0.74) were associated with significantly lower rates of treatment success.

CONCLUSIONS

Despite major challenges, a high percentage of patients receiving anti-TB treatment before the hurricane were located and successfully treated in southwest Haiti. The lessons learned and results presented here may help inform policies and guidelines in similar settings for effective TB control after a natural disaster.

[Issues and Solutions in Mental Health and Work: Managers Perspectives of a Large Health Organization]

Mental health problems in the workplace represent an important issue for public organizations, particularly for people working in the health sector who have been confronted to multiple changes following the recent health system reform in Quebec. Managers need to take into consideration employee mental health within their organization in order to ensure productive and healthy employees. Managers are thus called upon to take on a role that includes prevention (e.g., detection of early warning signs), team management (e.g., working on recognition at work) and coaching employees in their tasks when returning to work following a sick leave due to a common mental disorder (e.g., depression). Although there is an abundant literature on the manager's role in the prevention of mental health problems in the workplace and the work rehabilitation of employees on sick leave due to a common mental disorder, to our knowledge, little research has been conducted on these issues regarding managers' perceptions working in large health organizations. Furthermore, potential solutions have not been explored in this context. Objective The purpose of the study is to document, from the managers' perspective within a large health organization in Quebec, the issues pertaining to mental health and work (from prevention to work rehabilitation), and the solutions to deal with them. Method As part of a participatory research project, researchers and collaborators of a large health organization conducted focus groups with managers on the theme of mental health and work: issues and solutions. A total of 83 managers spread out in 10 focus groups participated in this study. Results From these focus groups, 6 broad categories of issues related to mental health in the workplace emerged: 1) the management framework, 2) human, financial, material and information resource management, 3) management of mental health and tools, 4), stakeholders' collaboration, roles and actions, 5) employees' sense of belonging to the organization and, 6) work-life balance. From these broad conceptual categories, 23 specific issues and associated solutions emerged. Conclusions From this study, the general consensus was the need to have access to a series of tools (e.g., toolbox) in order to assist managers across the different steps, from sick-leave prevention, to rehabilitation and return to work. The results also highlighted the need to better define the roles of each stakeholder in this process. These results bring a new light to the issues and potential solutions perceived by managers dealing with mental health and work issues in a large health organization. These results could eventually be replicated in other settings or large organizations.