Rachel E Patzer1, Mengyu Di2, Rebecca Zhang3, Laura McPherson4, Derek A DuBay5, Matthew Ellis6, Joshua Wolf7, Heather Jones8, Carlos Zayas5, Laura Mulloy9, Amber Reeves-Daniel10, Sumit Mohan11, Aubriana C Perez2, Amal N Trivedi12, Stephen O Pastan13. 1. Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia; Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia. Electronic address: rpatzer@emory.edu. 2. Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia. 3. Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia. 4. Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia. 5. Medical University of South Carolina, Charleston, South Carolina. 6. Department of Medicine and Department of Surgery, Duke University, Durham, North Carolina. 7. Piedmont Transplant Institute, Piedmont Healthcare, Atlanta, Georgia. 8. Vidant Medical Center, Greenville, North Carolina. 9. Division of Nephrology, Department of Medicine, Augusta University, Augusta, Georgia. 10. Wake Forest Medical Center, Winston-Salem, North Carolina. 11. Departments of Medicine and Epidemiology, Columbia University Irving Medical Center, New York, New York. 12. Brown University School of Public Health, Providence, Rhode Island; Center of Innovation in Long-term Services and Supports, Providence VA Medical Center, Providence, Rhode Island. 13. Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia; Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia.
Abstract
RATIONALE & OBJECTIVE: The national kidney allocation system (KAS) implemented in December 2014 in the United States redefined the start of waiting time from the time of waitlisting to the time of kidney failure. Waitlisting has declined post-KAS, but it is unknown if this is due to transplant center practices or changes in dialysis facility referral and evaluation. The purpose of this study was to assess the impact of the 2014 KAS policy change on referral and evaluation for transplantation among a population of incident and prevalent patients with kidney failure. STUDY DESIGN: Cohort study. SETTING & PARTICIPANTS: 37,676 incident (2012-2016) patients in Georgia, North Carolina, and South Carolina identified within the US Renal Data System at 9 transplant centers and followed through December 2017. A prevalent population of 6,079 patients from the same centers receiving maintenance dialysis in 2012 but not referred for transplantation in 2012. EXPOSURE: KAS era (pre-KAS vs post-KAS). OUTCOME: Referral for transplantation, start of transplant evaluation, and waitlisting. ANALYTICAL APPROACH: Multivariable time-dependent Cox models for the incident and prevalent population. RESULTS: Among incident patients, KAS was associated with increased referrals (adjusted HR, 1.16 [95% CI, 1.12-1.20]) and evaluation starts among those referred (adjusted HR, 1.16 [95% CI, 1.10-1.21]), decreased overall waitlisting (adjusted HR, 0.70 [95% CI, 0.65-0.76]), and lower rates of active waitlisting among those evaluated compared to the pre-KAS era (adjusted HR, 0.81 [95% CI, 0.74-0.90]). Among the prevalent population, KAS was associated with increases in overall waitlisting (adjusted HR, 1.74 [95% CI, 1.15-2.63]) and active waitlisting among those evaluated (adjusted HR, 2.01 [95% CI, 1.16-3.49]), but had no significant impact on referral or evaluation starts among those referred. LIMITATIONS: Limited to 3 states, residual confounding. CONCLUSIONS: In the southeastern United States, the impact of KAS on steps to transplantation was different among incident and prevalent patients with kidney failure. Dialysis facilities referred more incident patients and transplant centers evaluated more incident patients after implementation of KAS, but fewer evaluated patients were placed onto the waitlist. Changes in dialysis facility and transplant center behaviors after KAS implementation may have influenced the observed changes in access to transplantation.
RATIONALE & OBJECTIVE: The national kidney allocation system (KAS) implemented in December 2014 in the United States redefined the start of waiting time from the time of waitlisting to the time of kidney failure. Waitlisting has declined post-KAS, but it is unknown if this is due to transplant center practices or changes in dialysis facility referral and evaluation. The purpose of this study was to assess the impact of the 2014 KAS policy change on referral and evaluation for transplantation among a population of incident and prevalent patients with kidney failure. STUDY DESIGN: Cohort study. SETTING & PARTICIPANTS: 37,676 incident (2012-2016) patients in Georgia, North Carolina, and South Carolina identified within the US Renal Data System at 9 transplant centers and followed through December 2017. A prevalent population of 6,079 patients from the same centers receiving maintenance dialysis in 2012 but not referred for transplantation in 2012. EXPOSURE: KAS era (pre-KAS vs post-KAS). OUTCOME: Referral for transplantation, start of transplant evaluation, and waitlisting. ANALYTICAL APPROACH: Multivariable time-dependent Cox models for the incident and prevalent population. RESULTS: Among incident patients, KAS was associated with increased referrals (adjusted HR, 1.16 [95% CI, 1.12-1.20]) and evaluation starts among those referred (adjusted HR, 1.16 [95% CI, 1.10-1.21]), decreased overall waitlisting (adjusted HR, 0.70 [95% CI, 0.65-0.76]), and lower rates of active waitlisting among those evaluated compared to the pre-KAS era (adjusted HR, 0.81 [95% CI, 0.74-0.90]). Among the prevalent population, KAS was associated with increases in overall waitlisting (adjusted HR, 1.74 [95% CI, 1.15-2.63]) and active waitlisting among those evaluated (adjusted HR, 2.01 [95% CI, 1.16-3.49]), but had no significant impact on referral or evaluation starts among those referred. LIMITATIONS: Limited to 3 states, residual confounding. CONCLUSIONS: In the southeastern United States, the impact of KAS on steps to transplantation was different among incident and prevalent patients with kidney failure. Dialysis facilities referred more incident patients and transplant centers evaluated more incident patients after implementation of KAS, but fewer evaluated patients were placed onto the waitlist. Changes in dialysis facility and transplant center behaviors after KAS implementation may have influenced the observed changes in access to transplantation.
Keywords:
Allocation time; health care access; health care policy; kidney allocation policy (KAS); kidney failure; kidney transplantation; transplant referral; waitlisting
Authors: Kristen L King; S Ali Husain; Jesse D Schold; Rachel E Patzer; Peter P Reese; Zhezhen Jin; Lloyd E Ratner; David J Cohen; Stephen O Pastan; Sumit Mohan Journal: J Am Soc Nephrol Date: 2020-10-09 Impact factor: 10.121
Authors: Xingyu Zhang; Taylor A Melanson; Laura C Plantinga; Mohua Basu; Stephen O Pastan; Sumit Mohan; David H Howard; Jason M Hockenberry; Michael D Garber; Rachel E Patzer Journal: Am J Transplant Date: 2018-04-18 Impact factor: 8.086
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Authors: Rachel E Patzer; Kayla Smith; Mohua Basu; Jennifer Gander; Sumit Mohan; Cam Escoffery; Laura Plantinga; Taylor Melanson; Sean Kalloo; Gary Green; Alex Berlin; Gary Renville; Teri Browne; Nicole Turgeon; Susan Caponi; Rebecca Zhang; Stephen Pastan Journal: Kidney Int Rep Date: 2017-02-09