Dialysis centers, the keepers of the kidney transplant waiting list, are producing more data and inspiring more policies than ever before. However, the existing quality measures of the comparison of dialysis facilities (DFC) for these centers do not include longitudinal measures, such as time to waitlist for transplantation, which encourage coordination of care through the spectrum of dialysis centers, nephrologists, hospitals and transplant centers.
A new study by a team of researchers at Brigham and Women’s Hospital aimed to fill this gap by investigating potential associations between patient, facility, and waiting list characteristics and a center’s DFC scores. Combining data from the US Renal Data System (USRDS) with assessments from DFC centers between 2013 and 2018, researchers found that higher-rated facilities had a 47% higher chance of being placed on patient waiting lists. . The results are published in JAMA network open.
Historically, quality measurement programs have focused on specific care sites, so our goal was to focus on the continuum of patient experience. We wanted to know if the current quality measures reflected the entire continuum of care and if patients receiving care at higher-rated centers were more likely to be enrolled for a kidney transplant. “
Thomas Tsai, MD, MPH, Brigham Surgery and Public Health Center (CSPH), Department of Surgery
Patients with end-stage renal disease (ESKD) no longer have viable kidneys that effectively filter the blood; thus, without treatment, dangerous levels of biological wastes persist inside the body. For these patients, there are few treatment options: dialysis, kidney transplantation or conservative management of the kidneys. 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 waiting list managed by the United Network for Organ Sharing (UNOS). The diagnosis of ESKD is life threatening, which further underlines the importance of a quality intervention after the diagnosis -; quality that is measured by the Medicare DFC star system. The star system represents nine separate health statistics, including deaths, hospitalizations, blood transfusions, and then ranks facilities for final scores.
To assess existing quality measures of dialysis centers, the researchers used USRDS data and -; after excluding patients who have attended unclassified centers or who have already received a transplant -; 507,581 one-year patient experiences were recorded in 6,661 unique facilities. The researchers then used this data to determine whether characteristics of patient, facility or kidney transplant waiting lists were associated with corresponding ratings from dialysis centers.
Comparing 5-star and 1-star facilities, the team found that these higher-rated facilities were associated with a 47% increased likelihood of being placed on a transplant waiting list. Additionally, the team found that black patients were less likely to be on the waitlist than white patients and were more likely to be in 1 and 2 star facilities. In addition, the team found that both urban and nonprofit schools had a higher likelihood of being on the waitlist, although institutions in urban settings had a higher likelihood of getting grades. 1 and 2 stars.
The authors hope that incorporating waitlist rates into current DFC assessments will incentivize referral rates and, in turn, increase the overall quality of facilities nationwide.
“Ultimately, we strive to empower patients to make good, informed decisions about dialysis facilities,” said lead author Joel Adler, MD, MPH, CSPH and the Brigham Transplant Surgery Division. “For patients who are familiar with this system and decide based on these quality measures, it is crucial that we incorporate variables such as wait list rates, which can dramatically change patient outcomes.”