| End-stage renal disease (ESRD) is a growing public health problem and is associated with a mortality rate of ~18% per year, despite advances in dialysis therapy. Kidney transplantation is the preferred treatment for ESRD patients since it enhances both quality of life and long-term survival. Although various clinical and immunologic predictors of transplant success have been elucidated over the last several years, there is still uncertainty about impact of kidney transplant center volume and other center characteristics on kidney transplant outcomes.;This thesis dissertation will explore the relation between provider characteristics (including transplant center or hospital) and the survival (patient and allograft) of U.S. adult kidney transplant recipients (KTR) by addressing the following three aims: (i) systematically assemble, summarize, and evaluate the methodologic quality and results of existing studies on the association between transplant center volume and kidney transplant outcomes; (ii) longitudinally assess the impact of average annual kidney transplant procedural volume and other center characteristics (i.e., profit status, number of inpatient beds, academic affiliation, presence of residency programs) on the survival (patient and allograft) of over 100,000 KTR from January 1, 1994 to December 31, 2003 (followed until December 31, 2004) in the United States Renal Data System; the effect of these provider factors on outcome will be studied by year of transplantation and in high-risk patient subgroups (e.g., expanded criteria donor kidney transplants); (iii) conduct a national survey of medical and surgical directors of all active, adult U.S. kidney transplant programs; data on the structural characteristics of kidney transplant programs, clinical practice patterns, and measures of medical/surgical teamwork will be obtained from self-administered questionnaires and the relation of these factors with kidney transplant center volume will be ascertained.;Understanding the impact of center characteristics and clinical practice patterns on the success of kidney transplantation will help define the causal role of these factors in influencing outcomes and provide a means to monitor/improve the quality of kidney transplantation. In addition, this work will provide a rationale for developing interventions that will improve the structure and processes of care for KTR, with the ultimate goal of optimizing long-term outcomes. |
