In the Journals

Study identifies variability in transplant process among dialysis centers, patients

Rachel E. Patzer

There was substantial variation among dialysis centers regarding referral and evaluation rates for kidney transplantation, according to this study. In addition, researchers observed differences in which patients were most likely to be referred and/or evaluated.

“The dialysis facility plays an important role in patient access to kidney transplantation, because the majority of ESKD patients start treatment on dialysis in the United States, with only 9.8% of kidney transplant recipients preemptively transplanted,” Rachel E. Patzer, PhD, MPH, of Emory University in Georgia, and colleagues wrote. “Variation in standardized transplantation ratios has been reported across both dialysis facilities and geographic regions, and the Centers for Medicare and Medicaid Services (CMS) proposed the proportion of prevalent dialysis patients waitlisted as a new quality metric for dialysis facilities in 2018 to address this variation.”

However, the researchers argued that placing patients on waitlists may not be the best metric to evaluate transplant access because it does not address “the important steps in the transplant process prior to waitlisting, such as educational practices in the dialysis facility, referral from a dialysis facility to a transplant center to undergo evaluation, and start of the transplant evaluation.”

To further examine these crucial early steps, as well as to look at associated dialysis-facility and patient-level factors, the researchers linked data from 690 dialysis centers (comprising of 34,857 patients) to referral and evaluation data from nine transplant centers in Georgia, North Carolina and South Carolina, noting the Southeast has the lowest rates of kidney transplantation in the United States.

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Reference: Patzer RE, et al. Am J Transplant. 2020;doi:10.1111/ajt.15791.

They found the median within-dialysis facility proportion of patients referred within 1 year was 33.7%, with a range of 0% to 100% (12 facilities with no referrals). Of referred patients, 16.1% started evaluation within 6 months of referral (35 facilities with no evaluations).

Regarding facility-level characteristics, the researchers determined facilities with the lowest referral rates had patients with a higher mean age, fewer mean number of black patients, fewer patients with hypertension as the cause of ESKD and a higher proportion of patients with more comorbidities (eg, diabetes and obesity). Furthermore, the lowest performing facilities were more likely to be for profit, with patients treated at such facilities having a 13% lower rate of referral and evaluation compared with non-profit centers. Dialysis facilities with the lowest referral performance had a lower patient to social worker ratio, while moderate-sized facilities (26 to 54 patients) had higher referral performance than other sizes (eg, 79 or more patients)

Characteristics of patients associated with greater likelihood of referral and evaluation included male sex and pre-ESKD nephrology care, while older age, female sex, Medicaid insurance and higher neighborhood poverty were associated with lower rates of referral and evaluation.

The researchers pointed out the “striking” finding that black patients were more likely to be referred for transplant than white patients, noting that “decades of research identifying racial/ethnic disparities in transplantation has suggested this disparity is at least partially explained by lower referral for transplant.” The lower transplant rates, as well as previously determined lower likelihood of black patients being waitlisted, may therefore be due to factors that occur after referral, they suggested. Furthermore, they wrote that a higher rate of preemptive referral among white patients may partially explain the higher referral rate among black patients already on dialysis. “Taken together,” they argued, “these results suggest that efforts to tackle the longstanding racial disparities in waitlisting and transplant access should focus interventions to reduce disparities on the step after referral, and prior to dialysis start.”

The researchers concluded the observed variations among dialysis facilities indicate a potential benefit to monitoring these early steps in national surveillance data, especially given that national policies are currently “promoting new payment reform for dialysis facilities to increase transplant access.” – by Melissa J. Webb

Disclosures: The authors report no relevant financial disclosures.

Rachel E. Patzer

There was substantial variation among dialysis centers regarding referral and evaluation rates for kidney transplantation, according to this study. In addition, researchers observed differences in which patients were most likely to be referred and/or evaluated.

“The dialysis facility plays an important role in patient access to kidney transplantation, because the majority of ESKD patients start treatment on dialysis in the United States, with only 9.8% of kidney transplant recipients preemptively transplanted,” Rachel E. Patzer, PhD, MPH, of Emory University in Georgia, and colleagues wrote. “Variation in standardized transplantation ratios has been reported across both dialysis facilities and geographic regions, and the Centers for Medicare and Medicaid Services (CMS) proposed the proportion of prevalent dialysis patients waitlisted as a new quality metric for dialysis facilities in 2018 to address this variation.”

However, the researchers argued that placing patients on waitlists may not be the best metric to evaluate transplant access because it does not address “the important steps in the transplant process prior to waitlisting, such as educational practices in the dialysis facility, referral from a dialysis facility to a transplant center to undergo evaluation, and start of the transplant evaluation.”

To further examine these crucial early steps, as well as to look at associated dialysis-facility and patient-level factors, the researchers linked data from 690 dialysis centers (comprising of 34,857 patients) to referral and evaluation data from nine transplant centers in Georgia, North Carolina and South Carolina, noting the Southeast has the lowest rates of kidney transplantation in the United States.

#
Reference: Patzer RE, et al. Am J Transplant. 2020;doi:10.1111/ajt.15791.

They found the median within-dialysis facility proportion of patients referred within 1 year was 33.7%, with a range of 0% to 100% (12 facilities with no referrals). Of referred patients, 16.1% started evaluation within 6 months of referral (35 facilities with no evaluations).

Regarding facility-level characteristics, the researchers determined facilities with the lowest referral rates had patients with a higher mean age, fewer mean number of black patients, fewer patients with hypertension as the cause of ESKD and a higher proportion of patients with more comorbidities (eg, diabetes and obesity). Furthermore, the lowest performing facilities were more likely to be for profit, with patients treated at such facilities having a 13% lower rate of referral and evaluation compared with non-profit centers. Dialysis facilities with the lowest referral performance had a lower patient to social worker ratio, while moderate-sized facilities (26 to 54 patients) had higher referral performance than other sizes (eg, 79 or more patients)

Characteristics of patients associated with greater likelihood of referral and evaluation included male sex and pre-ESKD nephrology care, while older age, female sex, Medicaid insurance and higher neighborhood poverty were associated with lower rates of referral and evaluation.

The researchers pointed out the “striking” finding that black patients were more likely to be referred for transplant than white patients, noting that “decades of research identifying racial/ethnic disparities in transplantation has suggested this disparity is at least partially explained by lower referral for transplant.” The lower transplant rates, as well as previously determined lower likelihood of black patients being waitlisted, may therefore be due to factors that occur after referral, they suggested. Furthermore, they wrote that a higher rate of preemptive referral among white patients may partially explain the higher referral rate among black patients already on dialysis. “Taken together,” they argued, “these results suggest that efforts to tackle the longstanding racial disparities in waitlisting and transplant access should focus interventions to reduce disparities on the step after referral, and prior to dialysis start.”

The researchers concluded the observed variations among dialysis facilities indicate a potential benefit to monitoring these early steps in national surveillance data, especially given that national policies are currently “promoting new payment reform for dialysis facilities to increase transplant access.” – by Melissa J. Webb

Disclosures: The authors report no relevant financial disclosures.