Abstract
RATIONALE & OBJECTIVE: Little is known about the relative importance of dialysis facilities and transplant centers on variability in starting an evaluation among patients referred for kidney transplant. The primary objective of this study was to leverage cross-classified multilevel modeling to simultaneously examine the contextual effects of dialysis facilities and transplant centers on variation in the start of the transplant evaluation process. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Dialysis patients referred for kidney transplant to transplant centers across the Southeast, Northeast, New York, or Ohio River Valley US regions from January 1, 2012, to December 31, 2020, were identified from the United States Renal Data System and the Early Steps to Transplant Access Registry and followed through June 30, 2021. A total of N=25,488 referred patients were nested with 1,720 dialysis facilities and 26 transplant centers. OUTCOMES: Starting an evaluation for kidney transplant at a transplant center within 6 months of referral. ANALYTICAL APPROACH: A series of multilevel models were performed to estimate the variability in starting an evaluation for kidney transplant within 6 months of referral. The between-dialysis facility and/or transplant center variation in starting an evaluation was quantified using the median OR. RESULTS: Among 25,488 dialysis patients referred for kidney transplantation, 51% of patients started an evaluation at a transplant center within 6 months of referral. In multilevel models, the median OR between transplant centers was higher (indicating higher unexplained variability) than the dialysis facility median OR, regardless of measured patient, dialysis facility, and transplant center characteristics. LIMITATIONS: Early transplant access data was limited to 20 of 48 transplant centers across these 4 regions. CONCLUSIONS: When taking dialysis facilities and transplant centers into account, variation in starting an evaluation for kidney transplant appeared at both the dialysis facility and transplant center-level but was more apparent among transplant centers.