Dialysis centers, the gatekeepers of kidney transplantation waitlisting, produce more data and inspire more policies today than ever before. However, existing Dialysis Facility Compare (DFC) quality metrics for these centers have not included longitudinal metrics, such as time to transplantation waitlisting, which incentivize coordinating care across the spectrum of dialysis centers, nephrologists, hospitals, and transplant centers.
A new study by a team of Brigham and Women's Hospital researchers aimed to fill this gap by investigating potential associations between patient, facility, and waitlisting characteristics and a center's DFC ratings. By combining data from the U.S. Renal Data System (USRDS) to DFC center ratings between 2013 and 2018, researchers found that higher-rated facilities yielded a 47 percent higher likelihood of waitlisting for patients. Results are published in JAMA Network Open.
Historically, quality metric programs have focused on specific sites of care, so our objective was to focus on the continuum of experience for the patient. We wanted to know if current quality measurements reflected the full continuum of care, and if patients receiving care at higher-rated centers were more likely to be listed for kidney transplantation."
Thomas Tsai, MD, MPH, Brigham's Center for Surgery and Public Health (CSPH), Department of Surgery
Patients with end-stage kidney disease (ESKD) no longer have viable kidneys that effectively filter blood; thus, without treatment, dangerous biowaste levels persist inside the body. For these patients, there are few treatment options: dialysis, kidney transplantation or conservative kidney management. Kidney transplantation is often the best option for patients, but to receive a transplant, patients must be referred by their dialysis center to a national waitlist managed by the United Network for Organ Sharing (UNOS). ESKD diagnosis is life-threatening, which further emphasizes the importance of quality intervention after diagnosis -; quality which is measured by the Medicare DFC star system. The star system accounts for nine separate health statistics, including deaths, hospitalizations, blood transfusions, and then ranks facilities to get final ratings.
To assess existing quality metrics of dialysis centers, researchers used the USRDS data and -; after excluding patients that attended unrated centers or had already received transplants -; 507,581 year-long patient experiences were captured from 6,661 unique facilities. The researchers used these data to then determine whether patient, facility, or kidney transplant waitlisting characteristics were associated with corresponding dialysis center ratings.
By comparing 5-star and 1-star facilities, the team found those higher-rated facilities to be associated with a 47 percent increased likelihood of waitlisting for transplantation. Additionally, the team found Black patients were less likely to be waitlisted than white patients, and they were more likely to be at 1- and 2-star facilities. Furthermore, the team found that both urban facilities and nonprofit facilities boasted higher likelihood of waitlisting, despite facilities in urban settings having higher likelihood of 1- and 2-star ratings.
The authors hope that the integration of waitlisting rates into current DFC ratings will incentivize greater referral rates and, in turn, increase overall nationwide facility quality.
"At the end of the day, we're struggling to empower patients to make good, informed decisions about dialysis facilities," said lead author Joel Adler, MD, MPH, of the Brigham's CSPH and Division of Transplant Surgery. "For patients experiencing this system and deciding based on these quality metrics, it's crucial that we integrate variables like waitlisting rates, which can radically change patient outcomes."
Adler, J.T., et al. (2021) Association of Public Reporting of Medicare Dialysis Facility Quality Ratings With Access to Kidney Transplantation. JAMA Network Open. doi.org/10.1001/jamanetworkopen.2021.26719.