Method Could Help Monitor Transplant Referrals from Dialysis Clinics

Tracy Hampton
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For patients with end stage renal disease (ESRD), barriers to kidney transplantation can come from a range of sources. Referral to a transplant center is an essential first step for patients who may be transplant candidates, and it’s one that relies on actions taken by the leadership and staff at dialysis centers.

The Centers for Medicare & Medicaid Services, as well as the kidney community, have called for the development of quality measures for dialysis facilities to improve performance and equity in access to kidney transplantation, but little progress has been made. As described in a recent Clinical Journal of the American Society of Nephrology article, a new method may be effective for assessing dialysis centers’ performance in this area.

“In the past several years, the Centers for Medicare & Medicaid Services has focused on increasing referrals among dialysis facilities as part of the Statement of Work for the 18 End Stage Renal Disease Networks. However, these data are not routinely collected and are not available to the public to determine whether some dialysis facilities are appropriately referring patients for kidney transplantation,” said senior author Rachel Patzer, PhD, of the Emory University School of Medicine. “Monitoring transplant referrals among dialysis facilities could help drive quality improvement and increase access to kidney transplantation.”

Waitlisting of patients is often used as a measure of how well dialysis facilities perform, yet it may not be an ideal quality performance metric for facilities. Patzer noted that the use of waitlisting as a performance metric may be problematic owing to geographic variability in waitlisting practices across the United States that are beyond the control of dialysis facilities.

So Patzer and her team developed a risk-adjusted quality metric—the Standardized Transplantation Referral Ratio (STReR)—to evaluate dialysis facility performance in transplantation referrals relative to a regional average with similar patient case-mix.

The researchers applied the measure to transplant referral data from 8308 ESRD patients within 249 dialysis facilities in the state of Georgia that were linked with United States Renal Data System data during the period 2008–2011, with follow-up through 2012. Facility STReRs in Georgia ranged from zero to 4.87. Seventy-seven percent of facilities had observed transplant referrals as expected. Similar numbers of facilities had referrals either greater or less then would be expected: 11% had referrals significantly greater than expected, and 12% had STReRs less than expected.

Conditions significantly associated with the likelihood of referral included age, race, sex, and comorbidity; however, most of the observed variation in dialysis facility referral performance was due to characteristics within a dialysis facility rather than patient factors. On average, 67% of the variability in STReRs was attributed to within-facility variation. Between-facility variation accounted for 33% of the variability in dialysis facility performance.

The study demonstrates a method for computing a standardized measure for transplant referral that could be used to monitor the transplant referral performance of dialysis facilities. The investigators expect the metric could be adapted in a larger, national population if national data on transplant referral are collected in the future. For this to happen, collection of national surveillance data on transplant referrals from the more than 5000 US dialysis facilities is essential. A Centers for Medicare & Medicaid expert review panel recommended collection of national data a decade ago.

In an accompanying editorial, Kevin Fowler of The Voice of the Patient, Inc., who is a kidney disease patient and a transplant recipient himself, stated that he was stunned that the data on kidney transplant referrals are not collected nationally.

“I am recommending immediate action,” he wrote. “I am requesting that the Centers for Medicare & Medicaid Services mandate that all dialysis facilities collect and record their kidney transplant referrals. This requirement is long overdue.”

Fowler noted that after additional studies are complete, it will be very interesting to learn about referral rates besides Georgia.

Obtaining meaningful information on transplant referrals from individual dialysis facilities across the country may help policymakers and clinicians identify gaps in quality and access of care, incentivize dialysis providers to increase referrals of appropriate candidates for transplantation, and lead to new evidence-based guidelines and interventions to increase access to kidney transplantation.

Study co-authors include Sudeshna Paul, PhD, Laura C. Plantinga, PhD, Stephen O. Pastan, MD, Jennifer C. Gander, PhD, and Sumit Mohan.

The article, entitled “Standardized Transplantation Referral Ratio to Assess Clinical Performance of Transplant Referral among Dialysis Facilities,” appeared online at on January 25, 2018, doi:10.2215/CJN.04690417