Association Between Dialysis Facility Ownership and Access to Kidney Transplantation

Abstract

IMPORTANCE For-profit (vs nonprofit) dialysis facilities have historically had lower kidney transplantation rates, but it is unknown if the pattern holds for living donor and deceased donor kidney transplantation, varies by facility ownership, or has persisted over time in a nationally representative population. OBJECTIVE To determine the association between dialysis facility ownership and placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study that included 1 585 947 patients treated at 6512 US dialysis facilities. Adult patients with incident end-stage kidney disease from the US Renal Data System (2000-2016) were linked with facility ownership (Dialysis Facility Compare) and characteristics (Dialysis Facility Report). EXPOSURES The primary exposure was dialysis facility ownership, which was categorized as nonprofit small chains, nonprofit independent facilities, for-profit large chains (>1000 facilities), for-profit small chains (<1000 facilities), and for-profit independent facilities. MAIN OUTCOMES AND MEASURES Access to kidney transplantation was defined as time from initiation of dialysis to placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant. Cumulative incidence differences and multivariable Cox models assessed the association between dialysis facility ownership and each outcome. RESULTS Among 1 585 947 patients, the median age was 65 years (interquartile range, 54-75 years), with 55.8% male, and 28.4% non-Hispanic black patients. Eighty-eight percent of patients received care at a for-profit dialysis facility. A total of 115 650 patients (7.3%) received care at 435 nonprofit small chain facilities; 66 539 (4.2%) at 325 nonprofit independent facilities; 527 458 (33.3%) at 2239 facilities of large for-profit chain 1; 525 997 (33.2%) at 2082 facilities of large for-profit chain 2; 245 633 (15.5%) at 997 for-profit small chain facilities; and 104 670 (6.6%) at 434 for-profit independent facilities. During the study period, 230 202 patients (14.5%) were placed on the deceased donor waiting list, 39 767 (2.5%) received a living donor kidney transplant, and 88 431 (5.6%) received a deceased donor kidney transplant. For-profit facilities had lower 5-year cumulative incidence differences for each outcome vs nonprofit facilities (deceased donor waiting list: −2.6% [95% CI, −2.8% to −2.4%]; receipt of a living donor kidney transplant: −0.9% [95% CI, −1.0% to −0.8%]; and receipt of a deceased donor kidney transplant: −1.4% [95% CI, −1.5% to −1.3%]). Adjusted Cox analyses showed lower relative rates for each outcome among patients treated at all for-profit vs all nonprofit dialysis facilities: deceased donor waiting list (hazard ratio [HR], 0.87 [95% CI, 0.86 to 0.88]); receipt of a living donor kidney transplant (HR, 0.82 [95% CI, 0.80 to 0....

Longer Distance From Dialysis Facility to Transplant Center Is Associated With Lower Access to Kidney Transplantation

“…The pathway to receiving a kidney transplant is complex and often long, starting from awareness of advanced chronic kidney disease, referral to and evaluation at a transplant center, waitlist registration (if deemed eligible), and, finally, surgery when a suitable organ becomes available. However, rates of referral, waitlist registration, and transplantation vary substantially across dialysis facilities in the United States, 5 – 8 potentially reflecting both individual- and system-level barriers during this complicated process. Dialysis facility factors that have been associated with higher transplantation rates include nonprofit status, higher number of staff per facility, and higher proportion of patients managed with peritoneal dialysis.…”

“…Dialysis facility factors that have been associated with higher transplantation rates include nonprofit status, higher number of staff per facility, and higher proportion of patients managed with peritoneal dialysis. 5 , 8 To our knowledge, the distance between the dialysis facility and transplant center (DFTC distance) has not been evaluated as a potential factor that may be associated with access to waitlist registration or kidney transplantation. If patients receiving dialysis care in facilities further from the transplant center are shown to have lower access to transplantation, then targeted dialysis facility- and system-level interventions could help optimize disparities in access to kidney transplantation.…”

Implementation of a Quality Improvement Strategy to Increase Outpatient Kidney Transplant Referrals

“…Observational studies demonstrate factors associated with low referral and assessment rates for kidney transplantation include racial and socioeconomic disparities, geographic factors, local transplant center density, and size as well as ownership of the referring dialysis facility. [9][10][11][12] Most of the literature regarding advanced CKD referral for transplant has focused on variations in the duration of nephrology care before ESKD [1,13]. Thus, the process of kidney transplantation referrals from CKD nephrology clinics is understudied.…”

Implementation of a quality improvement strategy to increase outpatient kidney transplant referrals

“…Referral from an outpatient nephrology clinic or dialysis unit to the transplant center is a critical initial step toward successful kidney transplantation, and transplant education in early stages of CKD may increase rates of pre-emptive kidney transplant [5]. Observational studies demonstrate factors associated with low referral and assessment rates for kidney transplantation include racial and socioeconomic disparities, geographic factors, local transplant center density, and size as well as ownership of the referring dialysis facility [9][10][11][12]. Most of the literature regarding advanced CKD referral for transplant has focused on variations in the duration of nephrology care before ESKD [1,13].…”