Association Between Dialysis Facility Ownership and Access to Kidney Transplantation
Authors: Jennifer C. Gander, Xingyu Zhang, Katherine Ross, Adam S. Wilk, Laura McPherson, Teri Browne, Stephen O. Pastan, Elizabeth Walker, Zhensheng Wang, Rachel E. Patzer
Journal: JAMA (2019)

<h3>Importance</h3> For-profit (vs nonprofit) dialysis facilities have historically had lower kidney transplantation rates, but it is unknown if the pattern holds for living donor and deceased donor kidney transplantation, varies by facility ownership, or has persisted over time in a nationally representative population. <h3>Objective</h3> To determine the association between dialysis facility ownership and placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant. <h3>Design, Setting, and Participants</h3> Retrospective cohort study that included 1 585 947 patients treated at 6512 US dialysis facilities. Adult patients with incident end-stage kidney disease from the US Renal Data System (2000-2016) were linked with facility ownership (Dialysis Facility Compare) and characteristics (Dialysis Facility Report). <h3>Exposures</h3> The primary exposure was dialysis facility ownership, which was categorized as nonprofit small chains, nonprofit independent facilities, for-profit large chains (&gt;1000 facilities), for-profit small chains (&lt;1000 facilities), and for-profit independent facilities. <h3>Main Outcomes and Measures</h3> Access to kidney transplantation was defined as time from initiation of dialysis to placement on the deceased donor kidney transplantation waiting list, receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant. Cumulative incidence differences and multivariable Cox models assessed the association between dialysis facility ownership and each outcome. <h3>Results</h3> Among 1 585 947 patients, the median age was 65 years (interquartile range, 54-75 years), with 55.8% male, and 28.4% non-Hispanic black patients. Eighty-eight percent of patients received care at a for-profit dialysis facility. A total of 115 650 patients (7.3%) received care at 435 nonprofit small chain facilities; 66 539 (4.2%) at 325 nonprofit independent facilities; 527 458 (33.3%) at 2239 facilities of large for-profit chain 1; 525 997 (33.2%) at 2082 facilities of large for-profit chain 2; 245 633 (15.5%) at 997 for-profit small chain facilities; and 104 670 (6.6%) at 434 for-profit independent facilities. During the study period, 230 202 patients (14.5%) were placed on the deceased donor waiting list, 39 767 (2.5%) received a living donor kidney transplant, and 88 431 (5.6%) received a deceased donor kidney transplant. For-profit facilities had lower 5-year cumulative incidence differences for each outcome vs nonprofit facilities (deceased donor waiting list: −2.6% [95% CI, −2.8% to −2.4%]; receipt of a living donor kidney transplant: −0.9% [95% CI, −1.0% to −0.8%]; and receipt of a deceased donor kidney transplant: −1.4% [95% CI, −1.5% to −1.3%]). Adjusted Cox analyses showed lower relative rates for each outcome among patients treated at all for-profit vs all nonprofit dialysis facilities: deceased donor waiting list (hazard ratio [HR], 0.87 [95% CI, 0.86 to 0.88]); receipt of a living donor kidney transplant (HR, 0.82 [95% CI, 0.80 to 0.84]); and receipt of a deceased donor kidney transplant (HR, 0.83 [95% CI, 0.81 to 0.84]). <h3>Conclusions and Relevance</h3> Among US patients with end-stage kidney disease, receiving dialysis at for-profit facilities compared with nonprofit facilities was associated with a lower likelihood of accessing kidney transplantation. Given the possibility of residual confounding, the clinical and policy implications of the results are uncertain.