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Association Between Dialysis Facility Ownership and Access to Kidney Transplantation

Educational Objective
To understand barriers to kidney transplantation for patients with end-stage kidney disease.
1 Credit CME
Key Points

Question  Is dialysis facility ownership associated with access to kidney transplantation?

Findings  In this retrospective cohort study that included 1 478 564 patients with end-stage kidney disease treated at 6511 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 (−13.2%), receipt of a living donor kidney transplant (−2.3%), and receipt of a deceased donor kidney transplant (−4.3%).

Meaning  Receiving dialysis at for-profit facilities in the United States was associated with lower kidney transplantation rates.

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 1 478 564 patients treated at 6511 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 1 478 564 patients, the median age was 66 years (interquartile range, 55-76 years), with 55.3% male, and 28.1% non-Hispanic black patients. Eighty-seven percent of patients received care at a for-profit dialysis facility. A total of 109 030 patients (7.4%) received care at 435 nonprofit small chain facilities; 78 287 (5.3%) at 324 nonprofit independent facilities; 483 988 (32.7%) at 2239 facilities of large for-profit chain 1; 482 689 (32.6%) at 2082 facilities of large for-profit chain 2; 225 890 (15.3%) at 997 for-profit small chain facilities; and 98 680 (6.7%) at 434 for-profit independent facilities. During the study period, 121 680 patients (8.2%) were placed on the deceased donor waiting list, 23 762 (1.6%) received a living donor kidney transplant, and 49 290 (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% to −13.0%]; receipt of a living donor kidney transplant: −2.3% [95% CI, −2.4% to −2.3%]; and receipt of a deceased donor kidney transplant: −4.3% [95% CI, −4.4% to −4.2%]). 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], 0.36 [95% CI, 0.35 to 0.36]); receipt of a living donor kidney transplant (HR, 0.52 [95% CI, 0.51 to 0.54]); and receipt of a deceased donor kidney transplant (HR, 0.44 [95% CI, 0.44 to 0.45]).

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. Further research is needed to understand the mechanisms behind this association.

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Article Information

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 (rpatzer@emory.edu).

Accepted for Publication: August 6, 2019.

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.

Other: Walker.

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.

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