Disentangling Dialysis Facility and Transplant Center Factors on Evaluation Start Following Referral for Kidney Transplantation: A Regional Study in the United States
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...
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Elsevier
2025-04-01
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| Series: | Kidney Medicine |
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| Online Access: | http://www.sciencedirect.com/science/article/pii/S259005952500010X |
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| author | Laura McPherson Laura C. Plantinga Penelope P. Howards Michael Kramer Rachel E. Patzer |
| author_facet | Laura McPherson Laura C. Plantinga Penelope P. Howards Michael Kramer Rachel E. Patzer |
| author_sort | Laura McPherson |
| collection | DOAJ |
| description | 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. |
| format | Article |
| id | doaj-art-8d9919ed83bd4532a2235f7772d5710a |
| institution | OA Journals |
| issn | 2590-0595 |
| language | English |
| publishDate | 2025-04-01 |
| publisher | Elsevier |
| record_format | Article |
| series | Kidney Medicine |
| spelling | doaj-art-8d9919ed83bd4532a2235f7772d5710a2025-08-20T01:57:48ZengElsevierKidney Medicine2590-05952025-04-017410097410.1016/j.xkme.2025.100974Disentangling Dialysis Facility and Transplant Center Factors on Evaluation Start Following Referral for Kidney Transplantation: A Regional Study in the United StatesLaura McPherson0Laura C. Plantinga1Penelope P. Howards2Michael Kramer3Rachel E. Patzer4Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA; Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA; Address for Correspondence: Laura McPherson, PhD, Rollins School of Public Health, Department of Epidemiology, Emory University’s Laney Graduate School, 1518 Clifton Road NE, Atlanta, GA 30312.Divisions of Rheumatology and Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CADepartment of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GADepartment of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GADivision of Transplantation, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; Regenstrief Institute, Indianapolis, INRationale & 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.http://www.sciencedirect.com/science/article/pii/S259005952500010XDialysis facilitiesevaluation starthealth equitykidney transplantationtransplant centers |
| spellingShingle | Laura McPherson Laura C. Plantinga Penelope P. Howards Michael Kramer Rachel E. Patzer Disentangling Dialysis Facility and Transplant Center Factors on Evaluation Start Following Referral for Kidney Transplantation: A Regional Study in the United States Kidney Medicine Dialysis facilities evaluation start health equity kidney transplantation transplant centers |
| title | Disentangling Dialysis Facility and Transplant Center Factors on Evaluation Start Following Referral for Kidney Transplantation: A Regional Study in the United States |
| title_full | Disentangling Dialysis Facility and Transplant Center Factors on Evaluation Start Following Referral for Kidney Transplantation: A Regional Study in the United States |
| title_fullStr | Disentangling Dialysis Facility and Transplant Center Factors on Evaluation Start Following Referral for Kidney Transplantation: A Regional Study in the United States |
| title_full_unstemmed | Disentangling Dialysis Facility and Transplant Center Factors on Evaluation Start Following Referral for Kidney Transplantation: A Regional Study in the United States |
| title_short | Disentangling Dialysis Facility and Transplant Center Factors on Evaluation Start Following Referral for Kidney Transplantation: A Regional Study in the United States |
| title_sort | disentangling dialysis facility and transplant center factors on evaluation start following referral for kidney transplantation a regional study in the united states |
| topic | Dialysis facilities evaluation start health equity kidney transplantation transplant centers |
| url | http://www.sciencedirect.com/science/article/pii/S259005952500010X |
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