Background: Variability in kidney transplant rates across U.S. dialysis units has been noted, yet little is known of the association of neighborhood-level factors around dialysis facilities with low standardized transplant ratios (STRs).

Methods: We geocoded Centers for Medicare and Medicaid Services Dialysis Facility Report data and linked it with Census American Community Survey Data (2007-2010) to examine neighborhood (census tract)-level factors associated with low kidney transplant rates among U.S. dialysis facilities.

Analyses were restricted to facilities with complete 4-year STR data. Multivariable-adjusted multilevel linear regression models were used to identify the neighborhood and facility characteristics associated with low 4-year average STR.

Results: Among 2,785 U.S. dialysis facilities treating 198,182 patients, there was wide geographic variability in facility-level STRs. Median 4-year average facility-level STRs ranged from 0.61 [interquartile range (IQR): 0.36, 0.94] in Network 6 (Southeastern Kidney Council) to 1.52 (IQR: 0.95, 2.18) in Network 1 (New England). In multivariable analyses, neighborhood factors associated with low STR (p<0.001) included lower median income, lower proportion of English speakers, and a higher proportion of the population with < a high school education. No association was observed between STR and the proportion of households without a vehicle, the proportion unemployed, the proportion of black households, or neighborhood poverty.

Conclusions: There is significant variability in facility-level STRs among U.S. dialysis facilities. The characteristics of the neighborhood in which a dialysis facility resides may influence patient access to transplant, independent of dialysis facility characteristics. Understanding factors associated with low transplant rates can be used to target interventions to low-performing dialysis facilities, in neighborhoods with the highest need to improve access to kidney transplantation.

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