Effect of age and care organization on sources of variation in kidney transplant waiting list registration

Abstract

Despite national guidelines, medical practices and kidney transplant waiting list registration policies may differ from one dialysis/transplant unit to another. Benefit risk assessment variations, especially for elderly patients, have also been described. The aim of this study was to identify sources of variation in early kidney transplant waiting list registration in France. Among 16 842 incident patients during the period 2016–2017, 4386 were registered on the kidney transplant waiting list at the start of, or during the first year after starting, dialysis (26%). We developed various log‐linear mixed effect regression models on three levels: patients, dialysis networks, and transplant centers. Variability was expressed as variance from the random intercepts (± standard error). Although patient characteristics have an important impact on the likelihood of registration, the overall magnitude of variability in registration was low and shared by dialysis networks and transplant centers. Between‐transplant center variability (0.23 ± 0.08) was 1.8 higher than between‐dialysis network variability (0.13 ± 0.004). Older age was associated with a lower probability of registration and greater variability between networks (0.04, 0.20, & 0.93 in the 18–64, 65–74, and 75–84 age groups). Targeted interventions should focus on elderly patients and/or certain regions with greater variability in waiting list access.

The new French kidney allocation system for donations after brain death: Rationale, implementation, and evaluation

“…The new KAS has thus far succeeded in reducing the gap between the Ile de France and the other regions but has had a limited impact on overall regional disparities, which also depend on variations in health resources, procurement activity, the ESRD continuum of care, and renal disease epidemiology 19,20 …”

Functional representation of the network organisation of dialysis activities in France: A novel level for assessing quality of care

“…However, access to transplantation, for example, involves all the professionals at different stages. The network approach has been used to explore variability in this practice [ 16 ]. As well, because home dialysis and self-care units are mainly provided by not-for-profit units, these patients are transferred to these units for chronic care and are transferred back to public or private for-profit hospital-based dialysis units if necessary (i.e., with worsening of the clinical condition) [ 17 ].…”

“…As part of an implementation of a quality care action, our approach can be used to identify networks that statistically differ from the other in a given outcome [ 16 ]. It can also be used to detect healthcare facilities with a high centrality score as a “bridgehead” for action.…”

“…It is a compromise between a useful level for action and homogeneity. This classification is now used in various French studies exploring variability in care practice [ 16 ].…”

Women’s Access to Kidney Transplantation in France: A Mixed Methods Research Protocol

“…To overcome these limitations, “mixture models” [ 67 , 68 ] will also be used because they combine a logistic regression model to estimate the probability of waitlisting (or transplantation) and a conditional proportional hazard model to take into account the delay between dialysis start and waitlisting (or between waitlisting and transplantation, or between dialysis start and transplantation). Moreover, multilevel analyses will be performed to take into account random effects on the dialysis network’s level (i.e., dialysis centers that work together to offer all different RRT types in a given area) [ 69 ]. These analyses will be carried out successively at the national, regional, departmental, and census-block levels.…”