Abstract
Improving the quality of dialysis care and access to kidney transplantation for patients with end-stage kidney disease is a national clinical and policy priority. The role of dialysis facility quality in increasing access to kidney transplantation is not known. To determine whether patient, facility, and kidney transplant waitlisting characteristics are associated with variations in dialysis center quality. This population-based cohort study is an analysis of US Renal Data System data and Medicare Dialysis Facility Compare (DFC) data from 2013 to 2018. Participants included all adult (aged ≥18 years) patients in the US Renal Data System beginning long-term dialysis in the US from 2013 to 2017 with follow-up through the end of 2018. Patients with a prior kidney transplant and matched Medicare DFC star ratings to each annual cohort of recipients were excluded. Patients at facilities without a star rating in that year were also excluded. Data analysis was performed from January to April 2021. Dialysis center quality, as defined by Medicare DFC star ratings. The primary outcome was the proportion of patients undergoing incident dialysis who were waitlisted within 1 year of dialysis initiation. Secondary outcomes were patient and facility characteristics. Of 507 581 patients beginning long-term dialysis in the US from 2013 to 2017, 291 802 (57.4%) were male, 266 517 (52.5%) were White, and the median (interquartile range) age was 65 (55-75) years. Of 5869 dialysis facilities in 2017, 132 (2.2%) were 1-star, 436 (7.4%) were 2-star, 2047 (34.9%) were 3-star, 1660 (28.3%) were 4-star, and 1594 (27.2%) were 5-star. Higher-quality dialysis facilities were associated with 47% higher odds of transplant waitlisting (odds ratio [OR], 1.47; 95% CI, 1.39-1.57 for 5-star facilities vs 1-star facilities; P < .001). Black patients were less likely than White patients to be waitlisted for transplantation (OR, 0.74; 95% CI, 0.72-0.76). In addition, patients at for-profit (OR, 0.78; 95% CI, 0.74-0.81) and rural (OR, 0.63; 95%, CI 0.58-0.68) facilities were less likely to be waitlisted for transplantation compared with those at nonprofit and urban facilities, respectively. In this cohort study, patients at higher-quality dialysis facilities had higher odds than patients at lower-quality facilities of being waitlisted for kidney transplantation within 1 year. Waitlisting rates for kidney transplantation should be considered for integration into the current Centers for Medicare & Medicaid Services DFC star ratings to incentivize dialysis facility referral to transplant centers, inform patient choice, and drive quality improvement by increasing transplant waitlisting rates.
Highlights
Improving the quality of dialysis care and access to transplantation for patients living with end-stage kidney disease (ESKD) has been a major US health policy goal
Waitlisting rates for kidney transplantation should be considered for integration into the current Centers for Medicare & Medicaid Services Dialysis Facility Compare (DFC) star ratings to incentivize dialysis facility referral to transplant centers, inform patient choice, and drive quality improvement by increasing transplant waitlisting rates
A key component is through public reporting of quality metrics and a pay-for-performance program to incentivize increased transplant waitlisting rates: the Expanding Treatment Choices (ETC) model under the Advancing American Kidney Health initiative will adjust Medicare dialysis payments according to dialysis facility–level transplant waitlisting measured by the percentage of prevalent patients waitlisted (PPPW)
Summary
Improving the quality of dialysis care and access to transplantation for patients living with end-stage kidney disease (ESKD) has been a major US health policy goal. A key component is through public reporting of quality metrics and a pay-for-performance program to incentivize increased transplant waitlisting rates: the Expanding Treatment Choices (ETC) model under the Advancing American Kidney Health initiative will adjust Medicare dialysis payments according to dialysis facility–level transplant waitlisting measured by the percentage of prevalent patients waitlisted (PPPW). Prior studies[1,2] focused on the quality of care and accessibility of high-quality dialysis facilities, but it is unknown how dialysis facility quality is associated with waitlisting for kidney transplantation Understanding this association would offer a patient-centered metric of quality and access across the care continuum for patients with ESKD, and would assess alignment of incentives for dialysis facility quality improvement and pay-for-performance programs to increase access to transplantation. Empirical data would be helpful to assess whether higher-quality dialysis facilities, which already achieve better dialysis clinical outcomes,[3,4] are associated with higher transplant waitlisting rates
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