Lower Rates of Kidney Transplantation at For-Profit Facilities

SEPTEMBER 10, 2019
Kenny Walter
Jennifer Gander, PhD

Jennifer Gander, PhD

New data from a retrospective cohort study shows a lower likelihood of kidney transplantation when patients receive dialysis at for-profit facilities.

Investigators, led by Jennifer C. Gander, PhD, Emory University School of Medicine, examined 1.5 million patients with incident end-stage kidney disease treated at 6511 US dialysis facilities from the US Renal Data System between 2000-2016, which was merged with dialysis facility-level data from the Dialysis Facility Compare in 2016 and the Dialysis Facility Report between 2013-2016.

Historically, for-profit dialysis facilities have lower kidney transplantation rates. However, it is unknown if the pattern holds true for both living donors and deceased donor kidney transplantation, varies by facility ownership, or has persisted over time in a nationally representative population.

The primary outcome of the study was access to kidney transplantation, which was classified as the placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or the receipt of a deceased donor kidney transplant, which were each analyzed separately.

The median age of the study’s population was 66 years old, while 55.3% of the study group was male. The investigators found that 87% of patients received care at a for-profit dialysis facility, 7.4% received care at 435 nonprofit small chain facilities, and 5.3% received care at 324 nonprofit independent facilities.

Also, during the 16-year study period, 8.2% of patients were placed on the deceased donor waiting list, 1.6% received a living donor kidney transplant, and 3.3% 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: −13.2% [95% CI, −13.4-−13.0]; receipt of a living donor kidney transplant: −2.3% [95% CI, −2.4-−2.3]; and receipt of a deceased donor kidney transplant: −4.3% [95% CI, −4.4-−4.2]),” the authors wrote.

The team also used adjusted Cox analysis and found lower relative rates for each outcome among patients treated at all for-profit facilities when compared with nonprofit dialysis facilities (deceased donor waiting list [HR, .36 [95% CI, .35-.36]); receipt of a living donor kidney transplant [HR, .52 (95% CI, .51-.54)]; and receipt of a deceased donor kidney transplant (HR, .44 [95% CI, .44-.45]).

“Among US patients with end-stage kidney disease, receiving dialysis at for-profit facilities compared with nonprofit facilities was associated with a lower likelihood of accessing kidney transplantation,” the authors wrote.

The team said further studies are warranted for a better understanding of the mechanism behind the association between for-profit facilities and a lower likelihood of accessing kidneys for transplants.

As of 2016, there are 700,000 adults in the US with end-stage kidney disease. However, only 14% of patients with this infliction are placed on the deceased donor kidney transplantation waiting list or receive transplants within 1 year of diagnosis.

In 2018, the Centers for Medicare & Medicaid (CMS) amended the final rule for the End-Stage Renal Disease Prospective Payment System by proposing a new dialysis facility quality metric to the End-Stage Renal Disease Quality Incentive Program to monitor the percentage of prevalent patients with end-stage kidney disease on the waiting list for transplantation.

In 2019, the CMS also proposed the End-Stage Renal Disease Treatment Choices Model to improve access to kidney transplantation.

The study, "Association Between Dialysis Facility Ownership and Access to Kidney Transplantation," was published online in JAMA.

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