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

Abstract

Background and objectives 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.Design, setting, participants, & measurements 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.Results 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.Conclusions 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.

Trends in Mineral Metabolism Treatment Strategies in Patients Receiving Hemodialysis in the United States

“…In fact, policy changes since 2015, such as addition of calcimimetics into the bundled PPS, may further affect practice and practice variation. Facility variation is common in hemodialysis care and has been reported in anemia management, dialysis access, timing of dialysis initiation, and kidney transplant referrals (19)(20)(21)(22). Our findings are generally consistent with results from the Dialysis Outcomes and Practice Patterns Study (DOPPS) that demonstrated substantial facility variation in cinacalcet use for mineral metabolism management (23).…”

Transplant center characteristics associated with living‐donor kidney transplantation: a cohort study with a hierarchical modeling approach

“…Transplant center organization and practice may influence transplantation activity. To the best of our knowledge, studies about the center effect in the field of transplantation focused on the role of dialysis facility characteristics on access to the waiting list, and the outcome on transplantation .…”

Impact of Navigators on First Visit to a Transplant Center, Waitlisting, and Kidney Transplantation

“…We hypothesized that kidney transplant recipients would be more effective as navigators, because they have already completed the steps in the transplant process. Other efforts to increase access to kidney transplantation include educating patients on dialysis about the option of transplantation, developing measures of transplant referral, streamlining the transplant workup, communicating with potential living donors, and disseminating data on rates of transplantation (15,(20)(21)(22)(23)(24).…”