Disentangling Dialysis Facility and Transplant Center Factors on Evaluation Start Following Referral for Kidney Transplantation: A Regional Study in the United States

Abstract

Rationale & Objective

Little is known about the relative importance of dialysis facilities and transplant centers on variability in starting an evaluation among patients referred for kidney transplant. The primary objective of this study was to leverage cross-classified multilevel modeling to simultaneously examine the contextual effects of dialysis facilities and transplant centers on variation in the start of the transplant evaluation process.

Study Design

Retrospective cohort study.

Setting & Participants

Dialysis patients referred for kidney transplant to transplant centers across the Southeast, Northeast, New York, or Ohio River Valley US regions from January 1, 2012, to December 31, 2020, were identified from the United States Renal Data System and the Early Steps to Transplant Access Registry and followed through June 30, 2021. A total of N=25,488 referred patients were nested with 1,720 dialysis facilities and 26 transplant centers.

Outcomes

Starting an evaluation for kidney transplant at a transplant center within 6 months of referral.

Analytical Approach

A series of multilevel models were performed to estimate the variability in starting an evaluation for kidney transplant within 6 months of referral. The between-dialysis facility and/or transplant center variation in starting an evaluation was quantified using the median OR.

Results

Among 25,488 dialysis patients referred for kidney transplantation, 51% of patients started an evaluation at a transplant center within 6 months of referral. In multilevel models, the median OR between transplant centers was higher (indicating higher unexplained variability) than the dialysis facility median OR, regardless of measured patient, dialysis facility, and transplant center characteristics.

Limitations

Early transplant access data was limited to 20 of 48 transplant centers across these 4 regions.

Conclusions

When taking dialysis facilities and transplant centers into account, variation in starting an evaluation for kidney transplant appeared at both the dialysis facility and transplant center-level but was more apparent among transplant centers.

Plain-Language Summary

Kidney transplantation is a life-saving treatment, but not all dialysis patients referred for transplant take the next step of starting their evaluation at a transplant center. Our study sought to understand the relative influence of dialysis facilities and transplant centers in starting an evaluation for kidney transplantation. When taking both dialysis facilities and transplant centers into account, we observed variation in starting an evaluation for kidney transplantation appeared at both the dialysis facility and transplant center-level but characteristics specific to transplant centers appeared to play a larger role in explaining these differences. These findings underscore the need for health system-level improvements to promote more equitable early access to kidney transplantation.