title: Referral for Kidney Transplantation and Indicators of Quality of Dialysis Care: A Cross-sectional Study.
abstract: BACKGROUND
  Dialysis facility performance measures to improve access to kidney transplantation are being considered. Referral of patients for kidney transplantation evaluation by the dialysis facility is one potential indicator, but limited data exist to evaluate whether referral is associated with existing dialysis facility quality indicators.
  
  
  METHODS
  Cross-sectional study.
  
  
  METHODS
  12,926 incident (July 2005 to September 2011) adult (aged 18-69 years) patients treated at 241 dialysis facilities with complete quality indicator information from US national registry data linked to transplantation referral data from all 3 Georgia kidney transplantation centers.
  
  
  METHODS
  Facility performance on dialysis quality indicators (high, intermediate, and low tertiles).
  
  
  RESULTS
  Percentages of patients referred within 1 year of dialysis therapy initiation at dialysis facility.
  
  
  RESULTS
  Overall, a median of 25.4% of patients were referred for kidney transplantation within 1 year of dialysis therapy initiation. Higher facility-level referral was associated with better performance with respect to standardized transplantation ratio (high, 28.6%; intermediate, 25.1%; and low, 22.9%; P=0.001) and percentage waitlisted (high, 30.7%; intermediate, 26.8%; and low, 19.2%; P<0.001). Facility-level referral was not associated with indicators of quality of care associated with dialysis therapy initiation, including percentage of incident patients being informed of transplantation options. For most non-transplantation-related indicators of high-quality care, including those capturing mortality, morbidity, and anemia management, better performance was not associated with higher facility-level transplantation referral.
  
  
  CONCLUSIONS
  Potential ecologic fallacy and residual confounding.
  
  
  CONCLUSIONS
  Transplantation referral among patients at dialysis facilities does not appear to be associated with overall quality of dialysis care at the facility. Quality indicators related to kidney transplantation were positively associated with, but not entirely correspondent with, higher percentages of patients referred for kidney transplantation evaluation from dialysis facilities. These results suggest that facility-level referral, which is within the control of the dialysis facility, may provide information about the quality of dialysis care beyond current indicators.
authors.affiliation: Department of Medicine, Emory University, Atlanta, GA; Department of Epidemiology, Emory University, Atlanta, GA. Electronic address: laura.plantinga@emory.edu.
authors.forename: Laura C
authors.initials: LC
authors.lastname: Plantinga
authors.affiliation: Department of Medicine, Emory University, Atlanta, GA; Emory Transplant Center, Emory Healthcare, Atlanta, GA.
authors.forename: Stephen O
authors.initials: SO
authors.lastname: Pastan
authors.affiliation: Department of Health Policy & Management, Emory University, Atlanta, GA.
authors.forename: Adam S
authors.initials: AS
authors.lastname: Wilk
authors.affiliation: Alliant Health Solutions, Raleigh, NC.
authors.forename: Jenna
authors.initials: J
authors.lastname: Krisher
authors.affiliation: Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA.
authors.forename: Laura
authors.initials: L
authors.lastname: Mulloy
authors.affiliation: Piedmont Transplant Institute, Piedmont Healthcare, Atlanta, GA.
authors.forename: Eric M
authors.initials: EM
authors.lastname: Gibney
authors.affiliation: Department of Epidemiology, Emory University, Atlanta, GA; Emory Transplant Center, Emory Healthcare, Atlanta, GA; Department of Surgery, Emory University, Atlanta, GA.
authors.forename: Rachel E
authors.initials: RE
authors.lastname: Patzer
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D019984:Quality Indicators, Health Care; D012017:Referral and Consultation; D006435:Renal Dialysis / Q000592:standards*; D055815:Young Adult
keywords: Quality of care; RRT modality; dialysis; dialysis facility; end-stage renal disease (ESRD); kidney transplantation; pay-for-performance; performance indicator; quality indicator; referral; renal replacement therapy (RRT)