Patients in the United States who receive dialysis at for-profit rather than nonprofit facilities are less likely to have access to kidney transplantation, according to a new report published in JAMA.
In a retrospective cohort study of 1,478,564 patients treated at 6511 dialysis facilities, Rachel E. Patzer, PhD, MPH, of Emory University School of Medicine in Atlanta, and colleagues found that receiving dialysis at a for-profit facility compared with a nonprofit facility was associated with a significant 64%, 48%, and 56% decreased likelihood of being placed on a deceased donor kidney transplantation waiting list, receiving a living donor kidney transplant, and receiving a deceased donor kidney transplant, respectively.
To the investigators’ knowledge, no previous studies have examined the relationship between dialysis facility profit status and both living donor or deceased donor kidney transplantation.
Dr Patzer’s team categorized dialysis facility ownership as nonprofit small chains, nonprofit independent facilities; for-profit large chains (more than 1000 facilities), for-profit small chains (less than 1000 facilities), and for-profit independent facilities. They referred to DaVita and Fresenius Medical Care as large for-profit chain 1 and large for-profit chain 2, respectively.
Of the 1,478,564 patients, 109,030 (7.4%) received care at 435 nonprofit small chain facilities; 483,988 (32.7%) received care at 2239 large for-profit chain 1 facilities; 482,689 (32.6%) received care at 2082 large for-profit chain 2 facilities; 225,890 (15.3%) received care at 997 for-profit small chain facilities; and 98,680 (6.7%) received care at 434 for-profit independent facilities.
Compared with patients who received dialysis at nonprofit small chain dialysis facilities, those treated at nonprofit independent facilities were almost 2.4 times more likely to be placed on the deceased donor transplantation waiting list, Dr Patzer and her collaborators reported. Patients who received dialysis at large for-profit chain 1, large for-profit chain 2, for-profit small chain, and for-profit independent chain facilities were 43%, 46%, 44%, and 40% less likely to be placed on the deceased donor transplantation waiting list, respectively.
In addition, compared with patients receiving dialysis in nonprofit small chain dialysis facilities, those receiving dialysis at nonprofit independent facilities were 71% more likely to receive a deceased donor transplant, whereas patients treated at large for-profit chain 1, large for-profit chain 2, for-profit small chain, and for-profit independent chain facilities were 40%, 41%, 40% and 41% less likely to receive a deceased donor transplant, respectively.
Patients who switched from a nonprofit to a for-profit facility were more likely to be placed on the deceased donor transplant waiting list or receive a deceased or living donor kidney compared with patients who initiated and continued dialysis at for-profit facilities, Dr Patzer and her colleagues reported.
Patients who received dialysis at all for-profit facilities were 48% less likely to receive a living donor transplant compared with patients who were treated at all nonprofit facilities, according to the investigators.
In an accompanying editorial, L. Ebony Boulware, MD, MPH, of Duke University School of Medicine in Durham, North Carolina, and coauthors said findings of the new study, taken together, “paint a bleak and discouraging picture on the function of the dialysis industry in assisting patients’ access to kidney transplantation overall, and they draw a particularly concerning light on how the business practices of different dialysis organizations might influence patients’ access to life-enhancing therapy.”
Gander JC, Zhang X, Ross K, et al. Association between dialysis facility ownership and access to kidney transplantation. JAMA. 2019;322:957-973. doi: 10.1001/jama.2019.12803
Boulware LE, Wang V, Powe NR. Improving access to kidney transplantation: Business as usual or new ways of doing business? JAMA. 2019;322:931-933.