Placement on the kidney transplant waitlist is more likely to occur at dialysis facilities rated high for quality care by the Center for Medicare & Medicaid Services, a new study finds.

Of 5869 dialysis facilities in the United States in 2017, 132 (2.2%) received 1 star, 436 (7.4%) received 2 stars, 2047 (34.9%) received 3 stars, 1660 (28.3%) received 4 stars, and 1594 (27.2%) received 5 stars for quality.  The star ratings were based on measures of mortality, hospitalization, dialysis adequacy, vascular access, blood transfusion, and hypercalcemia.

Compared with 1-star dialysis facilities, 4- or 5-star dialysis facilities had significant 42% and 47% increased odds of waitlisting patients for kidney transplantation within a year of dialysis initiation, Joel T. Adler, MD, MPH, of Brigham and Women’s Hospital in Boston, Massachusetts, and colleagues reported in JAMA Network Open. Most 1- and 2-star facilities were located in urban areas and served a higher percentage of minorities. As the patient-to-nurse and patient-to-social worker ratios increased, the odds of waitlist placement decreased (5% and 1%, respectively, per 10-patient increment).

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Patients receiving home dialysis and peritoneal dialysis had 1.5- and 2.2-fold increased odds of waitlist placement in the first year, compared with patients receiving in-center hemodialysis, the investigators reported. Compared with those at nonprofit and urban facilities, patients at for-profit and rural facilities had significant 22% and 37% decreased odds of early waitlisting, respectively. Large chain facilities had significant 4% decreased odds of placing patients within the first dialysis year compared with independent chains.

Patients informed of transplantation had significant 2.3-fold increased odds of waitlist placement within the first dialysis year, according to the investigators. Men had significant 32% increased odds of waitlisting compared with women. Black patients had 26% decreased odds of early placement compared with White patients.

Each 1 year increase in age was associated with significant 5% decreased odds of waitlist placement. Employment was associated with significant 2.4-fold increased odds of early waitlisting. Retirement was associated with significant 6% decreased odds.

Dr Adler’s team stated that “the wide variability in the proportion of waitlisted patients suggests that this may be an important target for a quality measure. In the context of changing payment models that are intended to improve ESKD care, attention to the association between dialysis facility quality and transplantation should guide future policy.”


Adler JT, Xiang L, Weissman JS, et al. Association of public reporting of Medicare dialysis facility quality ratings with access to kidney transplantation. JAMA Netw Open. doi:10.1001/jamanetworkopen.2021.26719