Dialysis facility and network factors associated with low kidney transplantation rates among United States dialysis facilities

Abstract

Variability in transplant rates between different dialysis units has been noted, yet little is known about facility-level factors associated with low standardized transplant ratios (STRs) across the United States End-stage Renal Disease (ESRD) Network regions. We analyzed Centers for Medicare & Medicaid Services Dialysis Facility Report data from 2007 to 2010 to examine facility-level factors associated with low STRs using multivariable mixed models. Among 4098 dialysis facilities treating 305 698 patients, there was wide variability in facility-level STRs across the 18 ESRD Networks. Four-year average STRs ranged from 0.69 (95% confidence interval [CI]: 0.64-0.73) in Network 6 (Southeastern Kidney Council) to 1.61 (95% CI: 1.47-1.76) in Network 1 (New England). Factors significantly associated with a lower STR (p < 0.0001) included for-profit status, facilities with higher percentage black patients, patients with no health insurance and patients with diabetes. A greater number of facility staff, more transplant centers per 10 000 ESRD patients and a higher percentage of patients who were employed or utilized peritoneal dialysis were associated with higher STRs. The lowest performing dialysis facilities were in the Southeastern United States. Understanding the modifiable facility-level factors associated with low transplant rates may inform interventions to improve access to transplantation.

Keywords: Dialysis facilities; ESRD Networks; kidney transplantation.

Figure 1. Conceptual model indicating hierarchical or nesting levels of explanatory variables of interest (left) in this study, the typical timeline to (nonpreemptive) transplant (right) and possible associations between them

Patient- (dark gray circle), facility–(light gray circle) and End-Stage Renal Disease (ESRD) Network–level (white circle) explanatory variables are hypothesized to influence multiple steps in access to transplantation (left). Italics, no data to address these variables were available for this analysis. SES, socioeconomic status; Tx, transplant. *At the aggregate level.

Figure 2. Map of the 18 End-Stage Renal Disease Networks in the United States

(Reprinted with Permission from the ESRD Network Forum.)

Figure 3. Age- and calendar year–adjusted standardized transplant ratios (STRs) among United States dialysis facilities, 2007–2010

This figure shows STRs, or the ratio of the observed to expected transplants for each dialysis facility in the Unite States. Mean STRs for End-Stage Renal Disease (ESRD) Network 6 (lowest STR) and ESRD Network 1 (highest STR) are plotted. The middle line depicts an STR of 1.0, where the observed number of transplants equals the expected number of transplants.