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Original Investigation
September 10, 2019

Association Between Dialysis Facility Ownership and Access to Kidney Transplantation

Author Affiliations
  • 1Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta
  • 2Applied Biostatistics Laboratory, School of Nursing, University of Michigan, Ann Arbor
  • 3Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
  • 4Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
  • 5Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
  • 6College of Social Work, University of South Carolina, Columbia
  • 7Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
  • 8Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia
JAMA. 2019;322(10):957-973. doi:10.1001/jama.2019.12803
Key Points

Question  Is dialysis facility ownership associated with access to kidney transplantation?

Findings  In this retrospective cohort study that included 1 478 564 patients with end-stage kidney disease treated at 6511 US dialysis facilities from 2000-2016, 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%).

Meaning  Receiving dialysis at for-profit facilities in the United States was associated with lower kidney transplantation rates.

Abstract

Importance  For-profit (vs nonprofit) dialysis facilities have historically had lower kidney transplantation rates, but it is unknown if the pattern holds for living donor and deceased donor kidney transplantation, varies by facility ownership, or has persisted over time in a nationally representative population.

Objective  To determine the association between dialysis facility ownership and placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant.

Design, Setting, and Participants  Retrospective cohort study that included 1 478 564 patients treated at 6511 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).

Exposures  The primary exposure was dialysis facility ownership, which was categorized as nonprofit small chains, nonprofit independent facilities, for-profit large chains (>1000 facilities), for-profit small chains (<1000 facilities), and for-profit independent facilities.

Main Outcomes and Measures  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. Cumulative incidence differences and multivariable Cox models assessed the association between dialysis facility ownership and each outcome.

Results  Among 1 478 564 patients, the median age was 66 years (interquartile range, 55-76 years), with 55.3% male, and 28.1% non-Hispanic black patients. Eighty-seven percent of patients received care at a for-profit dialysis facility. A total of 109 030 patients (7.4%) received care at 435 nonprofit small chain facilities; 78 287 (5.3%) at 324 nonprofit independent facilities; 483 988 (32.7%) at 2239 facilities of large for-profit chain 1; 482 689 (32.6%) at 2082 facilities of large for-profit chain 2; 225 890 (15.3%) at 997 for-profit small chain facilities; and 98 680 (6.7%) at 434 for-profit independent facilities. During the study period, 121 680 patients (8.2%) were placed on the deceased donor waiting list, 23 762 (1.6%) received a living donor kidney transplant, and 49 290 (3.3%) received a deceased donor kidney transplant. For-profit facilities had lower 5-year cumulative incidence differences for each outcome vs nonprofit facilities (deceased donor waiting list: −13.2% [95% CI, −13.4% to −13.0%]; receipt of a living donor kidney transplant: −2.3% [95% CI, −2.4% to −2.3%]; and receipt of a deceased donor kidney transplant: −4.3% [95% CI, −4.4% to −4.2%]). Adjusted Cox analyses showed lower relative rates for each outcome among patients treated at all for-profit vs all nonprofit dialysis facilities: deceased donor waiting list (hazard ratio [HR], 0.36 [95% CI, 0.35 to 0.36]); receipt of a living donor kidney transplant (HR, 0.52 [95% CI, 0.51 to 0.54]); and receipt of a deceased donor kidney transplant (HR, 0.44 [95% CI, 0.44 to 0.45]).

Conclusions and Relevance  Among US patients with end-stage kidney disease, receiving dialysis at for-profit facilities compared with nonprofit facilities was associated with a lower likelihood of accessing kidney transplantation. Further research is needed to understand the mechanisms behind this association.

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