Method assesses how well dialysis clinics refer patients for transplantation

A new method may be useful for assessing dialysis facilities' performance concerning referrals to transplant centers. The method, which is described in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN), may help improve patients' chances of receiving potentially life-saving kidney transplants.

Kidney transplantation is the optimal treatment for most patients with kidney failure; however, only about 13% of US kidney failure patients are waitlisted for transplantation, and of those, less than 20% get transplanted each year. Many patients with kidney failure are on dialysis, and referral from a dialysis facility to a transplant center for evaluation is an important step towards kidney transplantation.

Rachel Patzer, PhD, MPH, of the Emory University School of Medicine, and her colleagues have developed a new measure— the Standardized Transplantation Referral Ratio (STReR)—for assessing how well dialysis facilities refer patients for transplantation.

The researchers applied the measure to transplant referral data from 8308 kidney failure patients within 249 dialysis facilities in the state of Georgia that were linked with United States Renal Data System data from 2008-2011, with follow-up through 2012. Facility STReRs in Georgia ranged from zero to 4.87. Most (77%) facilities had observed referrals as expected, while 11% and 12% had STReRs significantly greater and less than expected, respectively. Age, race, sex, and comorbid conditions were significantly associated with the likelihood of referral; however, most of the observed variation in dialysis facility referral performance was due to characteristics within a dialysis facility rather than patient factors. (On average, 33% of the variability in STReRs was attributed to between-facility variation and 67% to within-facility variation, respectively.)

The study demonstrates a method for computing a standardized measure for transplant referral that could be used to monitor the transplant referral performance of dialysis facilities.

"In the past several years, the Centers for Medicare and Medicaid Services has focused on increasing referrals among dialysis facilities as part of the Statement of Work for the 18 End Stage Renal Disease Networks. However, these data are not routinely collected and are not available to the public to determine whether some dialysis facilities are appropriately referring patients for kidney transplantation," said Dr. Patzer. "Monitoring transplant referrals among dialysis facilities could help drive quality improvement and increase access to kidney transplantation."

In an accompanying editorial, Kevin Fowler (The Voice of the Patient, Inc.), a kidney disease patient and a transplant recipient himself, stated that he was stunned that the data on kidney transplant referrals are not collected nationally. "I am recommending immediate action," he wrote. "I am requesting that the Centers for Medicare and Medicaid Services mandate that all dialysis facilities collect and record their kidney transplant referrals. This requirement is long overdue."