Dialysis Facility Profit Status and Early Steps in Kidney Transplantation in the Southeastern United States

Abstract

Background and objectives: Dialysis facilities in the United States play a key role in access to kidney transplantation. Previous studies reported that patients treated at for-profit facilities are less likely to be waitlisted and receive a transplant, but their effect on early steps in the transplant process is unknown. The study's objective was to determine the association between dialysis facility profit status and critical steps in the transplantation process in Georgia, North Carolina, and South Carolina.

Design, setting, participants, & measurements: In this retrospective cohort study, we linked referral and evaluation data from all nine transplant centers in the Southeast with United States Renal Data System surveillance data. The cohort study included 33,651 patients with kidney failure initiating dialysis from January 1, 2012 to August 31, 2016. Patients were censored for event (date of referral, evaluation, or waitlisting), death, or end of study (August 31, 2017 for referral and March 1, 2018 for evaluation and waitlisting). The primary exposure was dialysis facility profit status: for profit versus nonprofit. The primary outcome was referral for evaluation at a transplant center after dialysis initiation. Secondary outcomes were start of evaluation at a transplant center after referral and waitlisting.

Results: Of the 33,651 patients with incident kidney failure, most received dialysis treatment at a for-profit facility (85%). For-profit (versus nonprofit) facilities had a lower cumulative incidence difference for referral within 1 year of dialysis (-4.5%; 95% confidence interval, -6.0% to -3.2%). In adjusted analyses, for-profit versus nonprofit facilities had lower referral (hazard ratio, 0.84; 95% confidence interval, 0.80 to 0.88). Start of evaluation within 6 months of referral (-1.0%; 95% confidence interval, -3.1% to 1.3%) and waitlisting within 6 months of evaluation (1.0%; 95% confidence interval, -1.2 to 3.3) did not meaningfully differ between groups.

Conclusions: Findings suggest lower access to referral among patients dialyzing in for-profit facilities in the Southeast United States, but no difference in starting the evaluation and waitlisting by facility profit status.

Keywords: United States Renal Data System; dialysis; end stage kidney disease; epidemiology and outcomes; kidney transplantation; transplantation.

Graphical abstract

Figure 1.

Data merge and cohort selection to examine the relationship between dialysis facility profit status and access to kidney transplantation. GA, Georgia;ID, identification; NC, North Carolina; SC, South Carolina; USRDS, United States Renal Data System; VA, Veterans Affairs.

Figure 2.

Patients receiving dialysis at for-profit (versus nonprofit) facilities had a lower cumulative incidence difference for referral within 1 year of dialysis. There was no meaningful difference between cumulative incidence of starting the evaluation within 6 months of referral (among referred patients) and being waitlisted within 6 months of evaluation (among evaluated patients) by dialysis facility profit status.(A) Cumulative incidence and cumulative incidence difference of referral for kidney transplantation by profit status among patients with incident kidney failure between January 1, 2012 and December 31, 2016. (B) Cumulative incidence and cumulative incidence difference of starting evaluation at a transplant center among patients with incident kidney failure between January 1, 2012 and December 31, 2016 who were referred. No significant cumulative incidence differences were observed between patients at for-profit versus nonprofit facilities in starting evaluation at 6, 12, and 24 months after being referred. (C) Cumulative incidence and cumulative incidence difference of waitlisting among patients with incident kidney failure between January 1, 2012 and December 31, 2016 who were evaluated at a transplant center. *The cumulative incidence difference between for-profit and nonprofit facilities was significant. ^aCumulative incidence was calculated using cumulative incidence function and adjusted for competing risk of death (logrank <0.001); ^b95% CIs for cumulative incidence difference were estimated by bootstrap method. 95% CIs, 95% confidence intervals.

Figure 2.

Patients receiving dialysis at for-profit (versus nonprofit) facilities had a lower cumulative incidence difference for referral within 1 year of dialysis. There was no meaningful difference between cumulative incidence of starting the evaluation within 6 months of referral (among referred patients) and being waitlisted within 6 months of evaluation (among evaluated patients) by dialysis facility profit status.(A) Cumulative incidence and cumulative incidence difference of referral for kidney transplantation by profit status among patients with incident kidney failure between January 1, 2012 and December 31, 2016. (B) Cumulative incidence and cumulative incidence difference of starting evaluation at a transplant center among patients with incident kidney failure between January 1, 2012 and December 31, 2016 who were referred. No significant cumulative incidence differences were observed between patients at for-profit versus nonprofit facilities in starting evaluation at 6, 12, and 24 months after being referred. (C) Cumulative incidence and cumulative incidence difference of waitlisting among patients with incident kidney failure between January 1, 2012 and December 31, 2016 who were evaluated at a transplant center. *The cumulative incidence difference between for-profit and nonprofit facilities was significant. ^aCumulative incidence was calculated using cumulative incidence function and adjusted for competing risk of death (logrank <0.001); ^b95% CIs for cumulative incidence difference were estimated by bootstrap method. 95% CIs, 95% confidence intervals.