title: Inequalities in transplant waiting list activation across Italian dialysis centers.
abstract: BACKGROUND
  The demand for kidney transplant exceeds organ supply; therefore, understanding patient-related and contextual factors associated with waiting list activation is key in ensuring that organ allocation is efficient and equitable. We sought to assess whether inequalities in wait-listing probability exist across centers and evaluate correlates of wait-listing in Italy.
  
  
  METHODS
  We linked the MigliorDialisi dataset (1,238 patients enrolled in 54 Italian hemodialysis centers) to administrative data concerning the activity of each participating center and contextual information abstracted from the Italian Institute of Statistics. We modeled the odds of waiting list activation for patients on dialysis by the subjects' sociodemographic, biomedical and psychosocial factors along with center-related and contextual factors.
  
  
  RESULTS
  The crude enlistment rate was 26% (95% CI 9-54) distributed as follows: 21, 34 and 33% in northern, central, and southern Italy, respectively (p < 0.01). Older patients with poorer health conditions and lower expectations toward transplantation outcomes were less likely to be wait-listed in multilevel multivariable logistic regression. In the fully adjusted model there was not a statistically significant variation in wait-listing across northern, central, and southern regions. However, the variance explained by center-related factors accounted for 12% (p < 0.01) of total variability in enlistment likelihood (20% in patients >65 years, p < 0.01).
  
  
  CONCLUSIONS
  Our results showed that inter-center variation exists after adjusting for case mix. Additionally, we identified individual modifiable factors associated with wait-listing inequalities.
authors.affiliation: Dipartimento di Scienze Mediche e di Comunità, Clinica del Lavoro Luigi Devoto, Università degli Studi di Milano, Milan, Italy. luca.neri@unimi.it
authors.forename: Luca
authors.initials: L
authors.lastname: Neri
authors.forename: Maurizio
authors.initials: M
authors.lastname: Gallieni
authors.forename: Lisa Allegra
authors.initials: LA
authors.lastname: Rocca Rey
authors.forename: Silvio Volmer
authors.initials: SV
authors.lastname: Bertoli
authors.forename: Vittorio
authors.initials: V
authors.lastname: Andreucci
authors.forename: Diego
authors.initials: D
authors.lastname: Brancaccio
mesh_terms: D000293:Adolescent; D000328:Adult; D017677:Age Distribution; D000368:Aged; D000554:Ambulatory Care Facilities / Q000706:statistics & numerical data*; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006304:Health Status; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006436:Hemodialysis Units, Hospital / Q000706:statistics & numerical data*; D006801:Humans; D007558:Italy; D007676:Kidney Failure, Chronic / Q000601:surgery*; D016030:Kidney Transplantation / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D006435:Renal Dialysis; D012959:Socioeconomic Factors; D014850:Waiting Lists; D055815:Young Adult