Defense Date
2026
Document Type
Dissertation
Degree Name
Doctor of Philosophy
Department
Health Administration
First Advisor
Shoou-Yih Daniel Lee
Abstract
Statement of problem and objectives: Waitlisting is an essential step towards kidney transplantation among people with end-stage kidney disease (ESRD). There are no universal standards for waitlisting ESRD patients and how waitlists are managed in kidney transplant programs is opaque and under-studied. This study investigated whether the quality ratings of kidney transplant programs based on their one-year survival rates were associated with waitlist outcomes, including the number of waitlist additions, waitlist removals, the risk profiles of patients added or removed from a kidney transplant program’s waitlist, and whether market competition among kidney transplant programs attenuated these relationships.
Procedure followed: This study employed a retrospective, observational design using secondary data from the USRDS, UNOS, and the SRTR to assess the relationships between one-year survival ratings, competition, and waitlist management activities using panel analysis methods. Competition was operationalized via the Herfindahl–Hirschman Index (HHI), and survival ratings were obtained from transplant program PSRs.
Results: Lower one-year survival ratings were associated with fewer waitlist additions and more waitlist removals for non-medical reasons. Competition attenuated the relationship between one-year survival ratings and waitlist additions, but not the relationship between ratings and waitlist removals. No association was found between one-year survival ratings, competition, and clinical risk for either waitlist additions or removals. A sensitivity analysis employing multilevel logistic regression on waitlist removals further supported the findings by demonstrating that both patient-level factors and quality ratings independently affected the likelihood of removal, but only one interaction between patient-level clinical risk and quality ratings reached significance: history of drug use.
Conclusions: The current quality rating framework may unintentionally restrict access to kidney transplantation. Moreover, waitlist “churn” may be an underrecognized consequence of the current quality rating framework.
Rights
© The Author
Is Part Of
VCU University Archives
Is Part Of
VCU Theses and Dissertations
Date of Submission
5-5-2025