Association of Public Reporting of Medicare Dialysis Facility Quality Ratings With Access to Kidney Transplantation

JAMA Netw Open. 2021 Sep 1;4(9):e2126719. doi: 10.1001/jamanetworkopen.2021.26719.


Importance: Improving the quality of dialysis care and access to kidney transplantation for patients with end-stage kidney disease is a national clinical and policy priority. The role of dialysis facility quality in increasing access to kidney transplantation is not known.

Objective: To determine whether patient, facility, and kidney transplant waitlisting characteristics are associated with variations in dialysis center quality.

Design, setting, and participants: This population-based cohort study is an analysis of US Renal Data System data and Medicare Dialysis Facility Compare (DFC) data from 2013 to 2018. Participants included all adult (aged ≥18 years) patients in the US Renal Data System beginning long-term dialysis in the US from 2013 to 2017 with follow-up through the end of 2018. Patients with a prior kidney transplant and matched Medicare DFC star ratings to each annual cohort of recipients were excluded. Patients at facilities without a star rating in that year were also excluded. Data analysis was performed from January to April 2021.

Exposures: Dialysis center quality, as defined by Medicare DFC star ratings.

Main outcomes and measures: The primary outcome was the proportion of patients undergoing incident dialysis who were waitlisted within 1 year of dialysis initiation. Secondary outcomes were patient and facility characteristics.

Results: Of 507 581 patients beginning long-term dialysis in the US from 2013 to 2017, 291 802 (57.4%) were male, 266 517 (52.5%) were White, and the median (interquartile range) age was 65 (55-75) years. Of 5869 dialysis facilities in 2017, 132 (2.2%) were 1-star, 436 (7.4%) were 2-star, 2047 (34.9%) were 3-star, 1660 (28.3%) were 4-star, and 1594 (27.2%) were 5-star. Higher-quality dialysis facilities were associated with 47% higher odds of transplant waitlisting (odds ratio [OR], 1.47; 95% CI, 1.39-1.57 for 5-star facilities vs 1-star facilities; P < .001). Black patients were less likely than White patients to be waitlisted for transplantation (OR, 0.74; 95% CI, 0.72-0.76). In addition, patients at for-profit (OR, 0.78; 95% CI, 0.74-0.81) and rural (OR, 0.63; 95%, CI 0.58-0.68) facilities were less likely to be waitlisted for transplantation compared with those at nonprofit and urban facilities, respectively.

Conclusions and relevance: In this cohort study, patients at higher-quality dialysis facilities had higher odds than patients at lower-quality facilities of being waitlisted for kidney transplantation within 1 year. Waitlisting rates for kidney transplantation should be considered for integration into the current Centers for Medicare & Medicaid Services DFC star ratings to incentivize dialysis facility referral to transplant centers, inform patient choice, and drive quality improvement by increasing transplant waitlisting rates.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Centers for Medicare and Medicaid Services, U.S.
  • Cohort Studies
  • Female
  • Health Services Accessibility / statistics & numerical data*
  • Humans
  • Kidney Failure, Chronic
  • Kidney Transplantation / statistics & numerical data*
  • Male
  • Medicare
  • Middle Aged
  • Patient Selection*
  • Quality of Health Care
  • Renal Dialysis
  • Social Determinants of Health / statistics & numerical data*
  • United States
  • Waiting Lists*