Variation in Dialysis Facility Referral for Kidney Transplantation Among Patients With End-Stage Renal Disease in Georgia.
OBJECTIVE
Dialysis facilities in the United States are required to educate patients with end-stage renal disease about all treatment options, including kidney transplantation. Patients receiving dialysis typically require a referral for kidney transplant evaluation at a transplant center from a dialysis facility to start the transplantation process, but the proportion of patients referred for transplantation is unknown.


OBJECTIVE
To describe variation in dialysis facility-level referral for kidney transplant evaluation and factors associated with referral among patients initiating dialysis in Georgia, the US state with the lowest kidney transplantation rates.


METHODS
Examination of United States Renal Data System data from a cohort of 15,279 incident, adult (18-69 years) patients with end-stage renal disease from 308 Georgia dialysis facilities from January 2005 to September 2011, followed up through September 2012, linked to kidney transplant referral data collected from adult transplant centers in Georgia in the same period.


METHODS
Referral for kidney transplant evaluation within 1 year of starting dialysis at any of the 3 Georgia transplant centers was the primary outcome; placement on the deceased donor waiting list was also examined.


RESULTS
The median within-facility percentage of patients referred within 1 year of starting dialysis was 24.4% (interquartile range, 16.7%-33.3%) and varied from 0% to 75.0%. Facilities in the lowest tertile of referral (<19.2%) were more likely to treat patients living in high-poverty neighborhoods (absolute difference, 21.8% [95% CI, 14.1%-29.4%]), had a higher patient to social worker ratio (difference, 22.5 [95% CI, 9.7-35.2]), and were more likely nonprofit (difference, 17.6% [95% CI, 7.7%-27.4%]) compared with facilities in the highest tertile of referral (>31.3%). In multivariable, multilevel analyses, factors associated with lower referral for transplantation, such as older age, white race, and nonprofit facility status, were not always consistent with the factors associated with lower waitlisting.


CONCLUSIONS
In Georgia overall, a limited proportion of patients treated with dialysis were referred for kidney transplant evaluation between 2005 and 2011, but there was substantial variability in referral among facilities. Variables associated with referral were not always associated with waitlisting, suggesting that different factors may account for disparities in referral.
Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia2Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia3Emory Transplant Center, Atlanta, Georgia.
Rachel E
RE
Patzer
Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia4Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
Laura C
LC
Plantinga
Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.
Sudeshna
S
Paul
Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.
Jennifer
J
Gander
Southeastern Kidney Council Inc of End Stage Renal Disease Network 6, Raleigh, North Carolina.
Jenna
J
Krisher
Southeastern Kidney Council Inc of End Stage Renal Disease Network 6, Raleigh, North Carolina.
Leighann
L
Sauls
Piedmont Transplant Institute, Piedmont Healthcare, Atlanta, Georgia.
Eric M
EM
Gibney
Division of Nephrology, Department of Medicine, Georgia Regents University, Augusta.
Laura
L
Mulloy
Emory Transplant Center, Atlanta, Georgia4Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
Stephen O
SO
Pastan
D000293:Adolescent; D000328:Adult; D000368:Aged; D000554:Ambulatory Care Facilities / Q000191:economics / Q000706:statistics & numerical data; D015331:Cohort Studies; D005260:Female; D005845:Georgia; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D011203:Poverty; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D006435:Renal Dialysis; D014850:Waiting Lists; D055815:Young Adult