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Author Notes:

Corresponding Author: Laura Plantinga, Division of Renal Medicine, Department of Medicine, Emory University, 101 Woodruff Circle, 5105 Woodruff Memorial Building, Atlanta, GA 30322. Phone: 404-727-3460; Fax: 404-727-3425; laura.plantinga@emory.edu

Contributions: Research idea and study design: LCP, SOP, REP; data acquisition: JK, LM, EMG, REP; data analysis/interpretation: LCP, ASW, REP; statistical analysis: LCP; supervision or mentorship: SOP, REP.

Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved.

LCP takes responsibility that this study has been reported honestly, accurately, and transparently; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

We thank the Southeastern Kidney Council and all of the members of the Southeastern Kidney Transplant Coalition.

Some of the data reported here have been supplied by the USRDS.

Additionally, this material was prepared with assistance from the Southeastern Kidney Council, contract Number HHSM-500-2013-NW006C, ESRD Network 6, funded by the CMS, an agency of the US Department of Health and Human Services.

The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as official policy or interpretation of the US government.

Financial Disclosure: Dr Pastan is a minority shareholder in Fresenius Dialysis, College Park, GA. The other authors declare that they have no other relevant financial interests.


Research Funding:

This work was supported by National Institute on Minority Health and Health Disparities R24MD008077.


  • Science & Technology
  • Life Sciences & Biomedicine
  • Urology & Nephrology
  • Quality of care
  • dialysis
  • kidney transplantation
  • referral
  • performance indicator
  • end-stage renal disease (ESRD)
  • dialysis facility
  • pay-for-performance
  • renal replacement therapy (RRT)
  • RRT modality
  • quality indicator

Referral for Kidney Transplantation and Indicators of Quality of Dialysis Care: A Cross-sectional Study


Journal Title:

American Journal of Kidney Diseases


Volume 69, Number 2


, Pages 257-265

Type of Work:

Article | Post-print: After Peer Review


Background Dialysis facility performance measures to improve access to kidney transplantation are being considered. Referral of patients for kidney transplantation evaluation by the dialysis facility is one potential indicator, but limited data exist to evaluate whether referral is associated with existing dialysis facility quality indicators. Study Design Cross-sectional study. Setting & Participants 12,926 incident (July 2005 to September 2011) adult (aged 18-69 years) patients treated at 241 dialysis facilities with complete quality indicator information from US national registry data linked to transplantation referral data from all 3 Georgia kidney transplantation centers. Factors Facility performance on dialysis quality indicators (high, intermediate, and low tertiles). Outcome Percentages of patients referred within 1 year of dialysis therapy initiation at dialysis facility. Results Overall, a median of 25.4% of patients were referred for kidney transplantation within 1 year of dialysis therapy initiation. Higher facility-level referral was associated with better performance with respect to standardized transplantation ratio (high, 28.6%; intermediate, 25.1%; and low, 22.9%; P = 0.001) and percentage waitlisted (high, 30.7%; intermediate, 26.8%; and low, 19.2%; P  <  0.001). Facility-level referral was not associated with indicators of quality of care associated with dialysis therapy initiation, including percentage of incident patients being informed of transplantation options. For most non−transplantation-related indicators of high-quality care, including those capturing mortality, morbidity, and anemia management, better performance was not associated with higher facility-level transplantation referral. Limitations Potential ecologic fallacy and residual confounding. Conclusions Transplantation referral among patients at dialysis facilities does not appear to be associated with overall quality of dialysis care at the facility. Quality indicators related to kidney transplantation were positively associated with, but not entirely correspondent with, higher percentages of patients referred for kidney transplantation evaluation from dialysis facilities. These results suggest that facility-level referral, which is within the control of the dialysis facility, may provide information about the quality of dialysis care beyond current indicators.

Copyright information:

© 2016 National Kidney Foundation, Inc.

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