Is the Profit Motive Hindering Kidney Transplants?

The likelihood of a patient receiving a kidney transplant differed according to whether a dialysis center was for-profit or nonprofit, a new study indicated.

With approximately 1,500,000 cases analyzed, patients who were receiving dialysis for end-stage renal disease at a for-profit center had a 64% lower probability of being placed on the deceased kidney donor waiting list compared with patients at a nonprofit dialysis center (HR 0.36, 95% CI 0.35-0.36).

In addition, reported Rachel Patzer, PhD, MPH, of Emory University School of Medicine in Atlanta, and colleagues, the patients at for-profit centers similarly saw a 48% lower likelihood of receiving a living donor kidney transplant (HR 0.52, 95% CI 0.51-0.54) and a 56% lower likelihood of receiving a deceased donor kidney transplant (HR 0.44, 95% CI 0.44-0.45) versus those at nonprofit centers.

As shown in the group’s study online in JAMA, the cumulative incidence differences over a 5-year period indicated that patients receiving dialysis at a for-profit center had significantly lower incidence rates of being placed on a donor list or receiving a kidney than did those at nonprofit centers:

• Placement on deceased donor waiting list: -13.2% (95% CI -13.4% to -13.0%)

• Receipt of a living donor kidney: -2.3% (95% CI -2.4% to -2.3%)

• Receipt of a deceased donor kidney: -4.3% (95% CI -4.4% to -4.2%)

“Clinician-level barriers, including clinician perception of the appropriateness of the possible transplantation, poor medical follow-up, time spent with patients, and format of transplant education, may lead to delays in access to transplantation, and could explain some of these findings, but are unmeasured in national data,” Patzer and co-authors pointed out.

For the retrospective cohort analysis, the team used data from the U.S. Renal Data System, including records of patients at over 6,500 dialysis facilities from 2000 to 2016. Among the nearly 1.5 million patients with end-stage renal disease included in the analysis, 87% were receiving dialysis at a for-profit facility versus only 13% at a nonprofit facility.

Of the patients receiving care at a for-profit dialysis facility, the majority were at a large chain facility, while only about a quarter of these patients had care at either a small chain or independent facility. The study results also uncovered that the majority of patients do not switch dialysis facilities during the course of their treatment, but if they do, it is often to another facility within the same profit status.

The distribution of patients’ insurance coverage was similar between those at nonprofit and for-profit facilities, with the majority of patients having Medicare. The type of dialysis was also similar, with 91% of patients at both types of facilities receiving in-center hemodialysis. Only about 8% of patients at each type of facility received peritoneal dialysis, and only about 1% of patients at for-profit and nonprofit facilities received home hemodialysis.

The distribution of patient comorbidities were also generally comparable between those at for-profit versus nonprofit centers, with about half of patients at each center type having diabetes as the attributed cause of his or her end-stage renal disease. About 84% of all patients at each center also had hypertension at the start of dialysis.

The researchers found that regardless of the type of dialysis center, patients whose end-stage renal disease was caused by glomerulonephritis versus diabetes had a higher chance of being placed on a deceased donor waiting list (HR 3.00, 95% CI 2.96-3.05), receiving a living donor kidney transplant (HR 5.95, 95% CI 5.76-6.15), or receiving a deceased donor kidney (HR 2.17, 95% CI 2.12-2.22).

These findings “paint a bleak and discouraging picture on the function of the dialysis industry in assisting patients’ access to kidney transplantation overall,” noted the authors of an accompanying editorial. “Assuming the findings of these studies and the report [by Patzer, et al.] are valid and unbiased, it might be reasonable to infer that for-profit dialysis organizations have systematically and disproportionately focused their resource investments to prioritize the delivery of dialysis services while paying less attention to ensuring patients receive transplants,” wrote L. Ebony Boulware, MD, MPH, of Duke University School of Medicine in Durham, North Carolina, and co-authors.

“If true, this conclusion should lead to a close examination of market forces (e.g., competition for regional dialysis market share), payment policies (e.g., lack of reimbursement for activities that promote transplantation), or both, that could hinder the alignment of business goals with patient and family-centered treatment options,” the editorialists stated.

last updated 09.10.2019