Association of Public Reporting of Medicare Dialysis Facility Quality Ratings With Access to Kidney Transplantation

Abstract

IMPORTANCE Improving the quality of dialysis care and access to kidney transplantation for patients with end-stage kidney disease is a national clinical and policy priority. The role of dialysis facility quality in increasing access to kidney transplantation is not known. OBJECTIVETo determine whether patient, facility, and kidney transplant waitlisting characteristics are associated with variations in dialysis center quality. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study is an analysis of US Renal Data System data and Medicare Dialysis Facility Compare (DFC) data from 2013 to 2018. Participants included all adult (aged Ն18 years) patients in the US Renal Data System beginning longterm dialysis in the US from 2013 to 2017 with follow-up through the end of 2018. Patients with a prior kidney transplant and matched Medicare DFC star ratings to each annual cohort of recipients were excluded. Patients at facilities without a star rating in that year were also excluded. Data analysis was performed from January to April 2021.EXPOSURES Dialysis center quality, as defined by Medicare DFC star ratings. MAIN OUTCOMES AND MEASURESThe primary outcome was the proportion of patients undergoing incident dialysis who were waitlisted within 1 year of dialysis initiation. Secondary outcomes were patient and facility characteristics. RESULTSOf 507 581 patients beginning long-term dialysis in the US from 2013 to 2017, 291 802 (57.4%) were male, 266 517 (52.5%) were White, and the median (interquartile range) age was 65 (55-75) years. Of 5869 dialysis facilities in 2017, 132 (2.2%) were 1-star, 436 (7.4%) were 2-star, 2047 (34.9%) were 3-star, 1660 (28.3%) were 4-star, and 1594 (27.2%) were 5-star. Higher-quality dialysis facilities were associated with 47% higher odds of transplant waitlisting (odds ratio [OR], 1.47; 95% CI, 1.39-1.57 for 5-star facilities vs 1-star facilities; P < .001). Black patients were less likely than White patients to be waitlisted for transplantation (OR, 0.74; 95% CI, 0.72-0.76). In addition, patients at for-profit (OR, 0.78; 95% CI, 0.74-0.81) and rural (OR, 0.63; 95%, CI 0.58-0.68) facilities were less likely to be waitlisted for transplantation compared with those at nonprofit and urban facilities, respectively. CONCLUSIONS AND RELEVANCEIn this cohort study, patients at higher-quality dialysis facilities had higher odds than patients at lower-quality facilities of being waitlisted for kidney transplantation within 1 year. Waitlisting rates for kidney transplantation should be considered for integration into the current Centers for Medicare & Medicaid Services DFC star ratings to incentivize dialysis facility referral to transplant centers, inform patient choice, and drive quality improvement by increasing transplant waitlisting rates.

The Association of Dialysis Facility Payer Mix With Access to Kidney Transplantation

“…Referral data are not available in the USRDS. Nevertheless, 1-year incidence of wait-listing is a useful proxy for early referral and a metric of access to transplantation . Although this study focuses on dialysis facilities, the transplant centers play an undeniable role in ensuring access, and the impact of insurance and payer mix among transplant centers warrants exploration in future work.…”

“…Our primary outcome was time until addition to the kidney transplant waiting list up to 1 year after dialysis initiation (patient-level). This outcome was chosen in line with existing federal policy priorities and quality measures . We censored for death within 1 year of listing.…”

Quantifying the association of individual-level characteristics with disparities in kidney transplant waitlist addition among people with HIV

“…Given the relatively recent advent of transplantation in this patient population, it is perhaps possible that increasing provider knowledge about transplantation among PWH, could yield higher referral and waitlisting rates. Numerous studies have demonstrated that facility-level characteristics such as Medicare dialysis facility quality rating, ownership status, and center philosophy impact likelihood of waitlist addition and thus, these characteristics may explain some of the remaining unexplained disparity [40][41][42]. Nationally, Medicaid expansion has been associated with increased waitlist addition rates and improved survival on dialysis [43,44].…”

Insurance Transitions from Employer-Based Insurance to Medicare and Waitlisting for Kidney Transplantation: Placing Marietta v. DaVita in Context

“…While this is not the only reason that patients may switch early, any increase in switching could increase the substantial cost that Medicare already bears from the nearly one third of patients who switch early. 2 Because Medicare as a primary insurer at dialysis initiation is associated with decreased waitlisting for kidney transplantation, 3–5 early switching to Medicare may also be associated with decreased waitlisting for transplantation. Given the uncertainty around the net effect of Marietta on waitlisting, we used a 10-year pre- Marietta cohort to ( 1 ) assess the frequency and characteristics of patients who switched early to Medicare and ( 2 ) estimate the association of early switching to Medicare with waitlisting for kidney transplantation.…”