Dialysis Facility Profit Status and Access to Early Steps in Kidney Transplantation in the Southeastern United States Open Access
Walker, Elizabeth (Spring 2020)
Dialysis facilities in the United States play a key role in end-stage renal disease (ESRD) patient access to kidney transplantation, the optimal treatment for ESRD patients. Patients require a referral from a dialysis facility to begin evaluation at a transplant center. Previous studies reported patients treated at for-profit facilities are less likely to be waitlisted and less likely to receive kidney transplants, but the impact of for-profit status on early steps in the transplant process is unknown as completion of these steps is not documented in national surveillance data. Though the Southeastern United States has the highest burden of ESRD, it is the region with the lowest rate of kidney transplantation. It is critical to understand and address barriers to access to transplantation in this region. This study collected referral data from all nine transplant centers in Georgia, North Carolina, and South Carolina to determine the association between dialysis facility profit status and access to two critical steps early in the transplantation process: referral for transplant and start of evaluation at a transplant center. Cumulative incidence differences and multivariable Cox models were used to examine the association between dialysis facility profit status and completion of each of these two steps. Of the 33,659 incident ESRD patients initiating dialysis from January 1, 2012 to August 31, 2016 in these states, most received dialysis care at a for-profit facility (n=29,599, 85.0%) compared to a non-profit facility (n=5,060, 15.0%). There were significantly more for-profit facilities (n=590, 15.1%) in the region than non-profit facilities (n=105, 84.9%), which is consistent with national trends. For-profit facilities had lower cumulative incidence differences for referral within 1 year of initiation of dialysis compared to non-profit facilities (-4.6% [95% confidence interval (CI): -8.7% to -0.1%]). In both crude and adjusted Cox analyses, for-profit facilities demonstrated lower rates of referral for transplant relative to non-profit facilities (Crude Hazard Ratio (HR) = 0.87 [95%CI: 0.78 to 0.97]; Adjusted HR = 0.85 [95%CI: 0.77 to 0.95]). Start of evaluation at a transplant center did not differ significantly between groups. For ESRD patients living in the Southeast, receiving dialysis at a for-profit facility was associated with a lower likelihood of receiving a referral for kidney transplantation, a key step early in the transplantation process. This study emphasizes the importance of studying earlier steps, prior to waitlisting, to understand and address barriers to transplantation in this population.
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