Study evaluates influence of for-profit dialysis centers on access to transplantation
Most nephrologists agree that a kidney transplant is the optimal choice for a patient with kidney disease — either preemptively or from a living or decreased donor. However, a study recently published in JAMA suggests the likelihood of a patient receiving any of those options or being referred for an evaluation can be influenced by who owns the dialysis facility.
Analyzing U.S. Renal Data System records on 1,478,564 patients with ESKD treated at 6,511 dialysis facilities from Jan. 1, 2000 to Dec. 31, 2016, Jennifer C. Gander, PhD, from the Center for Research and Evaluation, Kaiser Permanente Georgia, and colleagues found dialysis clinics owned by for-profit companies had a lower rate of referrals for transplant. The percentage of patients placed on the deceased donor kidney transplantation waitlist was 11.9% for those treated at non-profit small-chain facilities and was 29.8% for those treated at non-profit independent dialysis facilities. Among for-profit chains, including Fresenius Medical Care and DaVita Kidney Care, between 6.6% and 7% of patients were placed on the deceased donor transplant list. The authors said the study was the first to analyze all aspects of transplant referral comparing non-profit vs. for-profit dialysis centers, including placement on the deceased donor kidney transplantation waitlist, receipt of a living donor kidney transplant or receipt of a deceased donor kidney transplant.
“Evidence suggests for-profit dialysis facilities have a lower standardized transplantation ratio, and their patients are less likely to be waitlisted compared with non-profit facilities,” Gander and colleagues wrote, citing previous research. “Physicians at for-profit dialysis facilities are less likely to have detailed discussions with patients about transplantation or involve families in the discussion. This could lead to limited access to living donor kidney transplantation at for-profit dialysis facilities.”
Among patients in the study group, 87% were receiving dialysis at a for-profit center.
Challenges facing for-profits
By having a larger portion of patients in their care, for-profit dialysis centers face external challenges for successful transition of patients to transplant. In an editorial, “Transplant first, dialysis last,” Abhijit V. Kshirsagar, MD, MPH, and colleagues noted that, on average, for-profit dialysis centers were a further distance away from transplant centers in the study than non-profit dialysis centers, which was again magnified when compared with independent dialysis centers.
“Furthermore, some of the observed differences in transplant outcomes in the study are partly explained by residual confounders,” Kshirsagar and colleagues wrote. “The Centers for Medicare & Medicaid Services form CMS 2728, which was used to adjust for numerous demographic and medical factors, does not capture the evolving comorbidity burden. A potential clue to differential comorbidities were the higher hospitalization rate in for-profit centers vs. non-profit centers.”
They added, “Finally, there were a larger proportion of for-profit centers in the South, an area that has long-standing low transplant rates.”
In statements by DaVita Kidney Care and Fresenius Medical Care, both companies cited their progress and investment in innovation to increase the number of patients referred to transplant.
“DaVita’s teammates and physician partners are passionately committed to helping as many patients as possible get transplanted. We are highly focused on helping our patients get waitlisted and stay transplant-ready, and we celebrate with the 6,800 DaVita patients who received a transplant last year,” according to a statement issued to Nephrology News & Issues. “Transplant Smart, our award-winning educational program, is one example of our ongoing investment in innovation, in partnership with nephrologists and transplant centers.”
Fresenius said in a statement it also questioned the age of data used in the study to calculate the difference in transplant rates. Brad Puffer, senior director of corporate communications for Fresenius Medical Care, told Nephrology News & Issues:
“We are fully committed to ensuring our patients have access to a transplant as the first choice, with home treatment being the preferred option for dialysis. Our Fresenius Medical Care Foundation recently launched a groundbreaking initiative with Donate Life America to create the first national living donor registry and first at-home living donor testing kits. We believe this has the potential to open up transplant options for patients with kidney failure that were never possible before.
The study includes historical data back to 2000 that is not reflective of the current state of care,” Puffer said. “We are still examining the study to better understand the findings and conclusions. Dialysis Facility Report data actually shows that the first-time transplant rate in Fresenius Kidney Care facilities increased 9% between 2014 and 2017.
“Additionally, we recently brought together a group of transplant surgeons and nephrologists for a discussion about how we can better align and improve collaboration and have recently published peer-reviewed articles on this important topic.”
In an email interview about the study with Nephrology News & Issues, Rachel Patzer, PhD, MPH, associate professor and director of the Health Services Research Center at Emory University School of Medicine and the corresponding author on the JAMA study, said the researchers wanted to study information provided to patients before get referral for transplant.
“Important next steps are whether we see differences in profit status in some of these early steps to transplant (eg, referral and the start of the evaluation process), as there are many factors that influence wait listing and transplantation which may have less to do with the dialysis facility and more to do with the transplant center or the patient, such as whether the patient shows up to start the transplant evaluation process or whether the patient is medically eligible for a transplant, etc.,” Patzer said.
“This is an important future step,” she said.
Concerns about access
In another, L. Ebony Boulware, MD, MPH, and colleagues, noted that for-profit centers also treat a larger percentage of racial/ethnic minority patients and patients with lower economic status compared with not-for-profit centers. They noted this raises some concerns about access to transplant for these groups, which already face disparities in transplant rates.
“ ... These findings paint a bleak and discouraging picture on the function of the dialysis industry in assisting patients’ access to kidney transplantation overall, and they draw a particularly concerning light on how the business practices of different dialysis organizations might influence patients’ access to life-enhancing therapy,” they wrote.
Patzer said the authors looked at several factors that might increase referrals to transplant.
“We have seen that for-profit facilities have fewer social workers per 100 patients, which is potentially addressable and may help with educating more patients about transplant as a treatment option,” she said.
“It is required by law that all patients are educated about transplant as a treatment option within the first 60 days [of starting dialysis] and then annually thereafter,” Patzer told Nephrology News & Issues.
The authors also noted patients initially treated at non-profit centers who later switched to a for-profit center for dialysis care had a greater likelihood of getting a transplant.
“This may suggest there is something beneficial about the early exposure (eg, to education, transplant philosophy, etc.) at a nonprofit that may carry over even if someone switches to a for-profit facility after some time,” Patzer wrote. – by Mark E. Neumann
- Boulware LB, et al. JAMA. 2019; doi:10.1001/jama.2019.12784.
- Gander JC, et al. JAMA. 2019;doi:10.1001/jama.2019.12803.
- Kshirsagar AV, et al. JAMA. 2019;doi:10.1001/jamasurg.2019.4286.
Disclosures: Boulware, Gander, Kshirsagar, Patzer and Puffer report no relevant financial disclosures.