A study¹ released earlier this week in JAMA studied the question of whether dialysis facility ownership is associated with access to kidney transplantation.

Historically, for-profit dialysis facilities have had lower kidney transplantation rates for their patients, but it was previously unknown “if the patterns holds for living donor and deceased donor kidney transplantation, varies by facility ownership, or has persisted over time in a nationally representative population [US].”

Researchers from throughout the US contributed to this study by examining a “retrospective cohort study that included 1,478,564 patients treated at 6,511 US dialysis facilities. Adult patients with incident end-stage kidney disease from the US Renal Data System (2000-2016) were linked with facility ownership (Dialysis Facility Compare) and characteristics (Dialysis Facility Report.”

“Access to kidney transplantation was defined as time from initiation of dialysis to placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant”.

The study concluded that “patients receiving dialysis at for-profit facilities vs nonprofit facilities had significantly lower 5-year cumulative incidence rates for placement on the deceased donor kidney transplantation waiting list (−13.2%), receipt of a living donor kidney transplant (−2.3%), and receipt of a deceased donor kidney transplant (−4.3%)".

The authors described possible explanations for the findings, including: “Clinician-level barriers, including clinician perception of the appropriateness of the possible transplantation, poor medical follow-up, time spent with patients, and format of transplant education, may lead to delays in access to transplantation, and could explain some of these findings, but are unmeasured in national data. As well as possible limited allocation of staffing to enable transplant education, as prior research determined that increased staff many improve access to kidney transplantation².

In an accompanying editorial published by JAMA, the authors also explored possible explanations of the correlation found in the Gander et all study. They hypothesized, “it might be reasonable to infer that for-profit dialysis organizations have systematically and disproportionately focused their resource investments to prioritize the delivery of dialysis services while paying less attention to ensuring patients receive transplants. If true, this conclusion should lead to a close examination of market forces (eg, competition for regional dialysis market share), payment policies (eg, lack of reimbursement for activities that promote transplantation), or both, that could hinder the alignment of business goals with patient and family-centered treatment options”³.

The editorial continues with a look forward into development made that could hopefully turn the tide towards a higher proportion of dialysis patients receiving a life-saving transplant. “The US Department of Health and Human Services’ Advancing American Kidney Health Initiative proposes to enhance patients’ access to kidney transplantation and home dialysis treatment options in the coming years”.

Additionally, “a number of immediate actions have been ordered, including funding for research, changes to Medicare payment models, reforms to organ procurement and management systems, and support for living kidney donors. Five new Medicare payment models will provide new incentives to enhance transplantation rates. This comprehensive policy reform could pave the way for new ways of doing business”.

Resources

1. Gander JC, Zhang X, Ross K, et al. Association Between Dialysis Facility Ownership and Access to Kidney Transplantation. JAMA. 2019;322(10):957–973. doi: 10.1001/jama.2019.12803

2. Patzer  RE, Plantinga  L, Krisher  J, Pastan  SO.  Dialysis facility and network factors associated with low kidney transplantation rates among United States dialysis facilities.  Am J Transplant. 2014;14(7):1562-1572. doi: 10.1111/ajt.12749

3. Boulware LE, Wang V, Powe NR. Improving Access to Kidney Transplantation: Business as Usual or New Ways of Doing Business? JAMA. 2019;322(10):931–933. doi:10.1001/jama.2019.12784