Want to take quizzes and track your credits?
Is dialysis facility ownership associated with access to kidney transplantation?
In this retrospective cohort study that included 1 585 947 patients with end-stage kidney disease treated at 6512 US dialysis facilities from 2000-2016, patients receiving dialysis at for-profit facilities vs nonprofit facilities had significantly lower 5-year cumulative incidence rates for placement on the deceased donor kidney transplantation waiting list (−2.6%), receipt of a living donor kidney transplant (−0.9%), and receipt of a deceased donor kidney transplant (−1.4%).
Receiving dialysis at for-profit facilities in the United States was associated with lower kidney transplantation rates.
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.
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).
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.
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 0.84]); and receipt of a deceased donor kidney transplant (HR, 0.83 [95% CI, 0.81 to 0.84]).
Conclusions and Relevance
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. Given the possibility of residual confounding, the clinical and policy implications of the results are uncertain.
Sign in to take quiz and track your certificates
JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC
Corresponding Author: Rachel E. Patzer, PhD, MPH, Departments of Surgery and Medicine, Emory University School of Medicine, 101 Woodruff Cir, 5101 Woodruff Memorial Research Bldg, Atlanta, GA 30322 (firstname.lastname@example.org).
Accepted for Publication: August 6, 2019.
Retraction and Replacement: This article was retracted and replaced on April 21, 2020, to fix errors in the Key Points; Abstract; Results and Discussion sections; Figures 1 and 2; Tables 1, 2, and 3; and the eFigure and eTables 1 through 6 in Supplement 1 (see Supplement 2 for the retracted article with errors highlighted and Supplement 3 for the replacement article with corrections highlighted).
Author Contributions: Drs Gander and Patzer had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Gander, Ross, Browne, Pastan, Patzer.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Gander, Zhang, Ross, Browne, Wang, Patzer.
Critical revision of the manuscript for important intellectual content: Gander, Wilk, McPherson, Browne, Pastan, Walker, Patzer.
Statistical analysis: Gander, Zhang, Ross, Wilk, McPherson, Walker, Wang, Patzer.
Obtained funding: Gander, Patzer.
Administrative, technical, or material support: Gander, McPherson, Browne, Pastan, Walker, Patzer.
Supervision: Gander, Pastan, Patzer.
Conflict of Interest Disclosures: Dr Pastan reported receiving compensation and travel funds from ESRD Network 6 and receiving compensation from Retrophin Corporation. He is a shareholder of Old National Dialysis and a former minority owner of Fresenius College Park Dialysis; these companies were involved in litigation with Fresenius Medical Care, which has been resolved by binding arbitration. No other disclosures were reported.
Funding/Support: The study was supported in part by grant F32DK107191 from the National Institute of Diabetes and Digestive and Kidney Diseases, grants R01MD010290 and U01MD010611 from the National Institute on Minority Health and Health Disparities, and grants UL1TR002378 and TL1TR002382 from the National Center for Advancing Translational Sciences.
Role of the Funder/Sponsor: The funders/sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
Disclaimer: The data reported herein have been supplied by the US Renal Data System. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as official policy or interpretation of the US government.
Additional Contributions: We thank Charles Wilson, senior news producer at Last Week Tonight With John Oliver, for opening this topic for discussion during interviews with Drs Gander and Patzer leading to the dialysis episode that aired on May 14, 2017.
You currently have no searches saved.