Variation in Dialysis Facility Referral for Kidney Transplantation Among Patients With End-Stage Renal Disease in Georgia

Abstract

IMPORTANCE Dialysis facilities in the United States are required to educate patients with end-stage renal disease about all treatment options, including kidney transplantation. Patients receiving dialysis typically require a referral for kidney transplant evaluation at a transplant center from a dialysis facility to start the transplantation process, but the proportion of patients referred for transplantation is unknown.OBJECTIVE To describe variation in dialysis facility-level referral for kidney transplant evaluation and factors associated with referral among patients initiating dialysis in Georgia, the US state with the lowest kidney transplantation rates. DESIGN, SETTING, AND PARTICIPANTS Examination of United StatesRenal Data System data from a cohort of 15 279 incident, adult (18-69 years) patients with end-stage renal disease from 308 Georgia dialysis facilities from January 2005 to September 2011, followed up through September 2012, linked to kidney transplant referral data collected from adult transplant centers in Georgia in the same period. MAIN OUTCOMES AND MEASURESReferral for kidney transplant evaluation within 1 year of starting dialysis at any of the 3 Georgia transplant centers was the primary outcome; placement on the deceased donor waiting list was also examined. RESULTSThe median within-facility percentage of patients referred within 1 year of starting dialysis was 24.4% (interquartile range, 16.7%-33.3%) and varied from 0% to 75.0%. Facilities in the lowest tertile of referral (<19.2%) were more likely to treat patients living in high-poverty neighborhoods (absolute difference, 21.8% [95% CI, 14.1%-29.4%]), had a higher patient to social worker ratio (difference, 22.5 [95% CI, 9.7-35.2]), and were more likely nonprofit (difference, 17.6% [95% CI, 7.7%-27.4%]) compared with facilities in the highest tertile of referral (>31.3%). In multivariable, multilevel analyses, factors associated with lower referral for transplantation, such as older age, white race, and nonprofit facility status, were not always consistent with the factors associated with lower waitlisting. CONCLUSIONS AND RELEVANCEIn Georgia overall, a limited proportion of patients treated with dialysis were referred for kidney transplant evaluation between 2005 and 2011, but there was substantial variability in referral among facilities. Variables associated with referral were not always associated with waitlisting, suggesting that different factors may account for disparities in referral.

Standardized Transplantation Referral Ratio to Assess Performance of Transplant Referral among Dialysis Facilities

“…Patient-level data on transplant referrals between 2008 and 2012 were collected from all three transplant centers in the state of Georgia (Emory Transplant Center [Atlanta], Augusta University Medical Center [Augusta], and Piedmont Transplant Institute [Atlanta]) as previously described (3,16). ESRD Network 6 served as the data coordinating center and linked patient-level referral data with dialysis facility data by unique provider number.…”

“…Although national transplant referral data are unavailable, we recently collected patient referral data from all Georgia transplant centers as part of the Reducing Disparities in Access to Kidney Transplantation Community Study, and an extension of this data collection in other states is underway (13). The few studies that have examined transplant performance using transplant referral have used facility-level absolute referral rate to measure facility performance (3,14,15). In a recent study, we examined whether absolute facility referral was associated with other quality metrics within dialysis facilities and found that referral was not associated with other metrics, such as anemia management, morbidity, or mortality, and although referral was associated with waitlisting and transplantation, it was not entirely correspondent with these other measures of transplant access.…”

“…Prior research has attributed poor access to kidney transplantation to gaps along the continuum of care for patients with ESRD (2,3). Although the effects of dialysis facility-and patientlevel factors on waitlisting and transplantation have been studied (2)(3)(4)(5)(6)(7)(8)(9), their effects on earlier steps, such as receiving education about the benefits of transplantation and referral from dialysis facilities to a transplant center for evaluation, have been understudied. With statewide data collection on transplant referral through the Southeastern Kidney Transplant Coalition, we previously reported wide variation in facility referral for kidney transplantation in the state of Georgia, where some facilities referred no patients and others referred up to 76% of their patient population (3).…”

Cultural competency of a mobile, customized patient education tool for improving potential kidney transplant recipients’ knowledge and decision-making

“…[1] Inadequate education may particularly impact patients with lower socioeconomic status or members of racial/ethnic minorities, contributing to lower rates of referral and transplant listing [2][3][4][5][6]. In addition, patients may choose to reject high KDPI and PHS increased risk organs that are expected to provide benefit out of fear or incomplete understanding of the relative risk of death on dialysis.…”

Transplant Center Patient Navigator and Access to Transplantation among High-Risk Population

“…Finding the appropriate number of patients for a navigator may vary from center to center, and a lower navigator-to-patient ratio may be most beneficial in improving access to care. For example, we have previously reported that a lower social worker-to-patient ratio is associated with higher transplant referral in our state (41). Although upfront costs to the transplant center may be an issue, targeting the intervention to those patients most in need could help control transplant center costs.…”