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Am J Kidney Dis. 2017 Feb;69(2):257-265. doi: 10.1053/j.ajkd.2016.08.038. Epub 2016 Nov 20.

Referral for Kidney Transplantation and Indicators of Quality of Dialysis Care: A Cross-sectional Study.

Author information

1
Department of Medicine, Emory University, Atlanta, GA; Department of Epidemiology, Emory University, Atlanta, GA. Electronic address: laura.plantinga@emory.edu.
2
Department of Medicine, Emory University, Atlanta, GA; Emory Transplant Center, Emory Healthcare, Atlanta, GA.
3
Department of Health Policy & Management, Emory University, Atlanta, GA.
4
Alliant Health Solutions, Raleigh, NC.
5
Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA.
6
Piedmont Transplant Institute, Piedmont Healthcare, Atlanta, GA.
7
Department of Epidemiology, Emory University, Atlanta, GA; Emory Transplant Center, Emory Healthcare, Atlanta, GA; Department of Surgery, Emory University, Atlanta, GA.

Abstract

BACKGROUND:

Dialysis facility performance measures to improve access to kidney transplantation are being considered. Referral of patients for kidney transplantation evaluation by the dialysis facility is one potential indicator, but limited data exist to evaluate whether referral is associated with existing dialysis facility quality indicators.

STUDY DESIGN:

Cross-sectional study.

SETTING & PARTICIPANTS:

12,926 incident (July 2005 to September 2011) adult (aged 18-69 years) patients treated at 241 dialysis facilities with complete quality indicator information from US national registry data linked to transplantation referral data from all 3 Georgia kidney transplantation centers.

FACTORS:

Facility performance on dialysis quality indicators (high, intermediate, and low tertiles).

OUTCOME:

Percentages of patients referred within 1 year of dialysis therapy initiation at dialysis facility.

RESULTS:

Overall, a median of 25.4% of patients were referred for kidney transplantation within 1 year of dialysis therapy initiation. Higher facility-level referral was associated with better performance with respect to standardized transplantation ratio (high, 28.6%; intermediate, 25.1%; and low, 22.9%; P=0.001) and percentage waitlisted (high, 30.7%; intermediate, 26.8%; and low, 19.2%; P<0.001). Facility-level referral was not associated with indicators of quality of care associated with dialysis therapy initiation, including percentage of incident patients being informed of transplantation options. For most non-transplantation-related indicators of high-quality care, including those capturing mortality, morbidity, and anemia management, better performance was not associated with higher facility-level transplantation referral.

LIMITATIONS:

Potential ecologic fallacy and residual confounding.

CONCLUSIONS:

Transplantation referral among patients at dialysis facilities does not appear to be associated with overall quality of dialysis care at the facility. Quality indicators related to kidney transplantation were positively associated with, but not entirely correspondent with, higher percentages of patients referred for kidney transplantation evaluation from dialysis facilities. These results suggest that facility-level referral, which is within the control of the dialysis facility, may provide information about the quality of dialysis care beyond current indicators.

KEYWORDS:

Quality of care; RRT modality; dialysis; dialysis facility; end-stage renal disease (ESRD); kidney transplantation; pay-for-performance; performance indicator; quality indicator; referral; renal replacement therapy (RRT)

PMID:
27881246
PMCID:
PMC5263049
DOI:
10.1053/j.ajkd.2016.08.038
[Indexed for MEDLINE]
Free PMC Article

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