For-Profit Dialysis Patients Miss Out on Transplant Referral

Patients who receive dialysis at for-profit dialysis centers are less likely to be referred for transplant evaluation than those receiving dialysis in a nonprofit facility, at least in Georgia, North Carolina, and South Carolina, a retrospective cohort study indicates.

However, once patients have been referred, the median time from referral to evaluation for transplantation, as well as being waitlisted, did not differ between for-profit and nonprofit facilities, the same study shows.

“To our knowledge, this was the first study to examine the relationship between dialysis facility profit status and early steps in the transplantation process in a multistate region,” Laura J. McPherson, MPH, of Rollins School of Public Health, Emory University, Atlanta, Georgia, and colleagues observe.

“This…emphasizes the importance of studying earlier steps prior to waitlisting [in order] to understand and address barriers to transplantation,” the investigators add, in their article published online May 26 in the Clinical Journal of the American Society of Nephrology.

Commenting on the findings in an accompanying editorial, Isaac Hall, MD, and Divya Raghavan, MD, both from the University of Utah School of Medicine, Salt Lake City, point out that, given the benefits of transplantation over dialysis, it’s important to understand any barriers that might affect patient access to this life-altering procedure.

“There appears to be at least some cause for concern that for-profit facilities may be incentivized to aggressively control costs and maintain dialysis patient volumes to maximize financial returns to investors,” Hall and Raghavan observe.

And given that the proportion of for-profit facilities is likely to increase, “it is important to consider possible mitigation strategies,” the editorialists advise.

End-Stage Renal Failure

The study included 33,651 patients in end-stage renal failure who had started on dialysis between January 2012 and August 2016. Most of the cohort, at 85%, received dialysis care at a for-profit facility compared with only 15% who received dialysis at a nonprofit facility. The mean age of the overall group was 60 years, and 56% were non-Hispanic Blacks.

“Compared to patients treated in for-profit facilities, patients treated in nonprofit facilities had significantly higher proportions of all 11 assessed comorbidities with the exception of body mass index,” the authors note.

A total of 44% of the overall cohort were referred for transplantation during the 4-year study interval, including 43% of those receiving dialysis at a for-profit center versus 47% of those receiving dialysis at a nonprofit facility (P < .001).

After adjusting for all potential confounders including the primary cause of kidney failure and the presence of selected comorbidities, patients treated at a for-profit facility were 16% less likely to receive a referral for transplant evaluation compared to those treated at a nonprofit facility, researchers report.

Among those patients who were referred for transplant evaluation, the median time from initiation of dialysis to referral was longer, at 4.6 months, for patients treated at a for-profit facility, compared with a median of 3.8 months for those treated at a nonprofit center (P < .001).

On the other hand, of those patients who were evaluated for transplant, similar percentages were from for-profit facilities, at 53%, compared with 55% from nonprofit facilities. Similarly, 37% of those from a for-profit facility were waitlisted compared with 35% of those from nonprofit facilities. There was also no difference in median time between evaluation to waitlisting between for-profit and nonprofit facilities.

Several Explanations for Differences

“There are several explanations for our findings,” the authors observe. One possibility is that for-profit centers are simply under-referring patients who could be good candidates for kidney transplantation. Then again, a patients’ health status, as reflected by an increase in the proportion of underlying comorbidities, can delay the process of patients gaining access to transplantation.

“Importantly, however, in this study, patients treated in for-profit facilities were actually less likely to have comorbidities that could limit their eligibility for transplantation than those treated in nonprofit facilities — yet they were still less likely to receive a referral at all time points assessed,” McPherson and colleagues point out.

“The results of this study highlight the need to improve patient access to transplantation prior to waitlisting,” the authors observe.

“And our findings suggest that targeted interventions and policies may be needed to incentivize transplant access,” they suggest.

The new CMS Percentage of Prevalent Patients Waitlisted proposal was recently developed to specifically encourage dialysis facilities to increase the proportion of patients on dialysis who are waitlisted, they point out.

Potential Solutions

In their editorial, Hall and Raghavan say a potential solution is to simply have all patients initiating dialysis be automatically referred for transplantation if they meet certain basic criteria. Although patients could opt out of this process, “referrals for transplant evaluation would almost certainly increase,” Hall and Raghavan suggest.

On the other hand, such a policy could potentially overwhelm transplant centers with candidates that ultimately do not meet eligibility criteria for waitlisting, thus serving only to delay the evaluation and waitlisting of those who do prove to be eligible for transplant.

“The early steps in transplant access remain frustratingly opaque, indicating the ongoing need to address long-standing disparities and ensure equity in treatment options for patients with kidney failure,” the editorialists state. 

“[Current] findings lend credence to the idea that the medical community and regulatory agencies should be systematically collecting information about these steps at the national level,” they conclude.

The authors, Hall, and Raghavan have reported no relevant financial relationships.

CJASN. Published online May 26, 2021. Abstract, Editorial

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