For-profit dialysis facilities show lower transplant referral rates than nonprofit centers
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Patients who received dialysis treatments at for-profit facilities were 16% less likely to be referred for transplantation during a 4-year period than those who had treatments at nonprofit facilities, research showed.
The study, which involved data from nine transplant centers across the Southeastern United States, revealed no “meaningful differences” in the likelihood of starting evaluation or being placed on a waitlist among those who achieved referral.
“Dialysis facilities in the U.S. play a key role in access to kidney transplantation. Previous studies reported patients treated at for-profit facilities are less likely to be waitlisted and receive a transplant, but their impact on early steps in the transplant process is unknown,” Laura J. McPherson, MPH, of Emory University, and colleagues wrote. “The study’s objective is to determine the association between dialysis facility profit status and critical steps in the transplantation process in Georgia, North Carolina and South Carolina.”
McPherson and colleagues noted they selected facilities in these states because the region has the lowest transplant rate in the country, despite having the highest burden of kidney failure.
A total of 33,651 patients who received dialysis at for-profit (85%) or nonprofit (15%) facilities were included. Overall, 56% of patients in the study were “non-Hispanic Black.”
Exclusion was based on being evaluated, wait-listed or transplanted prior to dialysis initiation.
“Of note, among patients excluded, patients referred prior to dialysis start were more likely to be younger, have received nephrology care, have employer insurance and live in a neighborhood with [less than] 20% of residents living below the poverty line compared to the study population; they were also less likely to have [nine] of the 11 comorbidities compared to patients in the main analysis,” the researchers wrote.
Differences between facilities
Results showed 44% of patients were referred for transplant during the 4-year study period (43% in for-profit vs. 47% in nonprofit facilities), with patients treated at a for-profit facility experiencing a longer median time to referral than those treated at a nonprofit (4.6 months vs. 3.8 months).
For-profit facilities had a lower cumulative incidence difference for referral within 1 year of dialysis initiation (-4.5%).
After adjusting for a variety of factors (including age, sex, race/ethnicity, primary cause of kidney failure, comorbidities, facility size, pre- or post-kidney allocation system era and insurance status), researchers found patients treated at a for-profit facility were 16% less likely to receive a referral compared with patients treated at a nonprofit facility (hazard ratio = 0.84).
Areas to explore
“Our study offers insight into the practice patterns related to referral for transplantation, start of the transplant evaluation at the transplant center, and placement on the national deceased donor waiting list, but our study does not have detailed information about the mechanisms and reasons for these differences in referral between for profit and non-profit facilities,” co-investigator on the study Rachel E. Patzer, PhD, said in a related press release. “The reasons for these differences in referral could be due to differences in patients’ health status that are not measured in our dataset, or they could be due to other unmeasured factors such as limited time to educate or refer patients for transplant, or unconscious bias. Future research is still needed to better understand these mechanisms, such as through focus groups and interviews with patients and care provider team members.”
In an accompanying editorial, Divya Raghavan, MD, and Isaac E. Hall, MD, MS, both of the University of Utah School of Medicine, underscored the need for patients with kidney failure to have support in navigating the transplantation process.
“The early steps in transplant access remain frustratingly opaque, indicating the ongoing need to address long-standing disparities and ensure equity in treatment options for patients with kidney failure,” they wrote. “The work by McPherson [and colleagues] involves a voluntary data registry to track early steps in transplantation, and their findings lend credence to the idea that the medical community and regulatory agencies should be systematically collecting information about these steps at the national level. Further research in this area is necessary and could enable more targeted approaches to improve equity without diminishing utility by overwhelming individual transplant systems.”
Perspective
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Benjamin E. Hippen, MD, FASN, FAST
The study by McPherson and colleagues reports reduced rates of referral from for-profit vs. not-for-profit dialysis facilities in three states in the Southeastern United States.
One of the challenges with the data analysis is the authors incorrectly assume that incident patient attribution to a particular dialysis facility is static. A study by Erickson and colleagues reported that 21.5%, 9.2%, 8.2%, and 7.6% of patients switched facilities during the first, second, third, and fourth 90-day intervals, respectively, following dialysis initiation, a degree of patient flux not accounted for by the authors of this study.
Additionally, the authors excluded 6,154 patient data points from the analysis because, “Patient ID could not be matched to USRDS ID.” This represents an exclusion of 29.4% of patients, who presumably had a referral, evaluation and waitlisting disposition wholly unaccounted for in the study.
One particular finding is left unremarked: While referral rates from for-profit facilities appear lower, rates of evaluation by the transplant center of those referred patients are also lower. Yet, patients from for-profit facilities are more likely to be waitlisted (Table 2: unadjusted HR 1.11 and adjusted HR 1.05 for wait-listing from for-profit facilities and Figure 2C). Assuming the data is correct, this raises several questions:
- What could explain ostensibly lower rates of referral coupled with lower evaluation of referred patients, translating into higher rates of waitlisting for patients from for-profit facilities?
- Are nonprofit facilities referring more patients that ultimately do not prove to be transplant candidates?
- Given a non-trivial “crash” rate for new incident patients with ESRD, does systematizing earlier referral result in a higher evaluation “washout” rate?
- Since transplant waiting time is indexed back to a patient’s ESRD start date on the CMS 2728 form, are patients who are referred “later” (ie, after control of uremia, volume, anemia on dialysis) perhaps translating into a greater likelihood of success in making it to actual waitlisting at 12 months (Figure 2C)?
Ultimately, getting our patients to successful waitlisting, rather than merely referral, is the goal.
To that end, Fresenius Medical Care North America has developed facility level transplant-focused dashboards which permit tracking on the patient, attending physician, facility, market, regional and national levels, with waitlisting status now backstopped by the United Network for Organ Sharing database, updated in real time.
To improve the quality of referrals, Fresenius has deployed nurse case managers into facilities using health information exchanges to assemble a robust and clinically accurate problem list to accompany transplant referrals, a time and resource saver which will help transplant centers rapidly triage and put patients through the evaluation process.
The company is building new interfaces and networks to bring communication between transplant centers, facilities, nephrologists and (most importantly) patients into the 21st century.
References:
Erickson KF, et al. JAMA Netw Open. 2019;doi:10.1001/jamanetworkopen.2019.3987Hippen BE. Neph News & Issues. 2021. Available at: www.healio.com/news/nephrology/20210503/we-need-to-make-policy-changes-to-improve-transplant-rate
McPherson LJ, et al. CJASN.2021;doi:10.2215/CJN.17691120.
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