title: Dialysis chains and placement on the waiting list for a cadaveric kidney transplant.
abstract: BACKGROUND
  The proliferation of multi-unit for-profit dialysis chains in the ESRD industry has raised concerns for patient quality of care including access to renal transplantation therapy (RTT). The effect of dialysis facility chain status on RTT is unknown.
  
  
  METHODS
  Data from the United States Renal Data System were used to identify 4,465 dialysis facilities and 56,714 dialysis patients who started hemodialysis in 2006. Patients were followed from initiation of hemodialysis in 2006 to placement on the renal transplant waiting list or to December 31, 2009. The role of dialysis facility chain status (affiliation, size, and ownership) on placement on the renal transplant waiting list was evaluated by multi-level mixed-effect regression models that account for clustering within facilities.
  
  
  RESULTS
  Patients from for-profit chain facilities, compared to nonprofit chain facilities, were 13% (95% CI 0.77-0.98) less likely to be waitlisted. In contrast, among nonchains, facility ownership did not influence likelihood of being waitlisted. There was also a marginally significant difference in waiting list placement by chain size: large chains compared with mid or small chains were 8% (95% CI 0.84-1.00) less likely to place patients on the waiting list. After adjustment for patient and facility characteristics, dialysis facility chain affiliation (chain-affiliated or not) was not found to be independently associated with the likelihood of placement on the transplant waitlist.
  
  
  CONCLUSIONS
  Dialysis chain affiliation expands previously observed ownership-related differences in placement on the waiting list. For-profit ownership of dialysis chain facilities appears to be a significant impediment to access to renal transplants.
authors.affiliation: 1 Medical Technology and Practice Patterns Institute, Bethesda, MD. 2 Yale School of Public Health, New Haven, CT. 3 Address correspondence to: Dennis Cotter, M.S.E., Medical Technology and Practice Patterns Institute, 5272 River Road, Suite 500, Bethesda, MD.
authors.forename: Yi
authors.initials: Y
authors.lastname: Zhang
authors.forename: Mae
authors.initials: M
authors.lastname: Thamer
authors.forename: Onkar
authors.initials: O
authors.lastname: Kshirsagar
authors.forename: Dennis J
authors.initials: DJ
authors.lastname: Cotter
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Schlesinger
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D019981:Health Care Sector / Q000191:economics / Q000458:organization & administration* / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000191:economics / Q000628:therapy*; D016030:Kidney Transplantation / Q000191:economics; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D009939:Organizations, Nonprofit; D010067:Ownership; D012044:Regression Analysis; D006435:Renal Dialysis / Q000191:economics; D012189:Retrospective Studies; D014481:United States; D014850:Waiting Lists; D055815:Young Adult