Profit-Driven Dialysis Care Reduces Kidney Transplantation Odds

Patients with end-stage kidney disease (ESKD) who undergo dialysis at for-profit institutions are less likely to receive a kidney transplant, according to a new study.

Researchers at Emory University (Atlanta, GA, USA), Kaiser Permanente Georgia (Atlanta, USA), and other institutions conducted a retrospective study involving 1,478,564 patients (median age 66 years, 55.3% male) with ESKD receiving dialysis at one of 6,511 dialysis facilities in the United States between 2000 and 2016. Facilities were classified as for-profit larger chains with more than 1,000 facilities, large for-profit small chains with fewer than 1,000 facilities, small for-profit small chains, for-profit independent facilities, non-profit small chains, and non-profit independent facilities.

The primary exposure was dialysis facility ownership, with the main outcome being access to kidney transplantation, 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. The results revealed that 7.4% received dialysis care at 435 non-profit small chain facilities; 5.3% at 324 non-profit independent facilities; 32.7% at 2,239 facilities of larger for-profit chains; 32.6% at 2,082 facilities of large for-profit chain; 15.3% at 997 for-profit small chain facilities; and 6.7% at 434 for-profit independent facilities.

The researchers determined that over the 17-year study period, patients receiving care in for-profit facilities versus non-profit facilities had significantly lower waitlisting. In all, 11.9% of ESKD patients receiving care in non-profit small chain facilities were waitlisted for a kidney transplant, while 29.8% of patients receiving care in non-profit independent dialysis facilities were waitlisted. This is compared to 7% in one for-profit larger chain, 6.2% in another for-profit large chain, 6.6% in for-profit small chains, and 6.9% in for-profit independent facilities. The study was published on September 10, 2019, in JAMA.

“For-profit dialysis facilities have a higher profit margin when they have more patients on dialysis. In non-profit facilities, there is not the same emphasis on profit margins,” said senior author Rachel Patzer, PhD, MPH, of Emory University. “We hypothesize that this leads to fewer referrals for transplant among for-profit dialysis facilities, which may explain why there is a higher rate of wait-listing and living donor transplants among non-profit facilities compared to for-profit dialysis facilities.”

“Patients should advocate for themselves, and ask questions about all treatment options, including transplantation,” concluded Dr. Patzer, who further clarified that “not all patients are candidates for transplant, but patients should make sure to have these conversations with their medical providers to understand the risks, benefits, and steps needed to pursue kidney transplantation as a treatment option.”

Related Links:
Emory University
Kaiser Permanente Georgia