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Clin J Am Soc Nephrol. 2018 Feb 7;13(2):282-289. doi: 10.2215/CJN.04690417. Epub 2018 Jan 25.

Standardized Transplantation Referral Ratio to Assess Performance of Transplant Referral among Dialysis Facilities.

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Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.
Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
Renal Division, Department of Medicine and.
Emory Transplant Center, Atlanta, Georgia.
Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.
Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; and.
Department of Epidemiology, Mailman School of Public Health, New York, New York.
Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia;



For patients with ESRD, referral from a dialysis facility to a transplant center for evaluation is an important step toward kidney transplantation. However, a standardized measure for assessing clinical performance of dialysis facilities transplant access is lacking. We describe methodology for a new dialysis facility measure: the Standardized Transplantation Referral Ratio.


Transplant referral data from 8308 patients with incident ESRD within 249 dialysis facilities in the United States state of Georgia were linked with US Renal Data System data from January of 2008 to December of 2011, with follow-up through December of 2012. Facility-level expected referrals were computed from a two-stage Cox proportional hazards model after patient case mix risk adjustment including demographics and comorbidities. The Standardized Transplantation Referral Ratio (95% confidence interval) was calculated as a ratio of observed to expected referrals. Measure validity and reliability were assessed.


Over 2008-2011, facility Standardized Transplantation Referral Ratios in Georgia ranged from 0 to 4.87 (mean =1.16, SD=0.76). Most (77%) facilities had observed referrals as expected, whereas 11% and 12% had Standardized Transplantation Referral Ratios significantly greater than and less than expected, respectively. Age, race, sex, and comorbid conditions were significantly associated with the likelihood of referral, and they were included in risk adjustment for Standardized Transplantation Referral Ratio calculations. The Standardized Transplantation Referral Ratios were positively associated with evaluation, waitlisting, and transplantation (r=0.46, 0.35, and 0.20, respectively; P<0.01). On average, approximately 33% of the variability in Standardized Transplantation Referral Ratios was attributed to between-facility variation, and 67% of the variability in Standardized Transplantation Referral Ratios was attributed to within-facility variation.


The majority of observed variation in dialysis facility referral performance was due to characteristics within a dialysis facility rather than patient factors included in risk adjustment models. Our study shows a method for computing a facility-level standardized measure for transplant referral on the basis of a pilot sample of Georgia dialysis facilities that could be used to monitor transplant referral performance of dialysis facilities.


Comorbidity; Confidence Intervals; Demography; Diagnosis-Related Groups; Follow-Up Studies; Kidney Failure, Chronic; Proportional Hazards Models; Referral and Consultation; Reproducibility of Results; Risk Adjustment; end stage renal disease; evaluation referral; kidney transplantation; kidney, Probability; quality measure; renal dialysis

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