General Comment: This manuscript attempts to address regional variation in early kidney transplant access—an issue of real public health importance. But despite an impressive dataset, the study design, analytic strategy, and interpretive frame fall short of what is required for publication in JAMA.
More importantly, the paper fails to meet the deeper ethical obligation of health services research: to illuminate structural inequity in a way that informs just and meaningful action. By narrowly defining access, excluding patients who succeed early, and offering little practical inference, the study risks obscuring more than it reveals.
Major Conceptual and Ethical Failings: Exclusion of Preemptively Referred, Evaluated, and Listed Patients The authors explicitly remove all individuals referred, evaluated, or waitlisted before dialysis initiation—including over 150,000 patients who were preemptively listed. This design choice is methodologically convenient, but epistemically disastrous.
By eliminating the most successful access cases, the authors truncate the upper tail of the distribution, bias estimates of “access” downward, and erase precisely the kinds of structural advantage we most need to interrogate.
This has two critical consequences:
Regions with strong preemptive referral programs are penalized—their access may appear lower simply because their best performers were excluded.
Disparities are undermeasured—because the privileged group most likely to be preemptively listed (e.g., insured, White, educated, urban) is systematically removed from the analysis.
A paper that purports to inform policy and equity cannot justify excluding those who accessed the system earliest—especially without rigorous sensitivity analysis or commentary.
Additional Core Deficiencies:
Lack of Anchoring to Clinical Onset The authors provide no consistent temporal anchor to biological disease progression (e.g., ESRD diagnosis or dialysis start). Access must be understood in context: access to what, from when, and relative to whom?
Absence of a Hypothesis or Theory of Access There is no guiding conceptual framework. The study is descriptive but unstructured. It does not build toward explanation, prediction, or intervention.
No Inference to Practice or Policy Despite gesturing toward HRSA and IOTA, the paper offers no recommendations, thresholds, or frameworks that might guide action. JAMA publishes research that informs guidelines, legislation, or clinical behavior. This paper does none of those.
Analytic Ambiguity “Evaluation start” is inconsistently defined across centers. Results are presented as facility-level tertiles without clearly adjusted models. The inclusion of Fine-Gray models in the supplement is not integrated into the main interpretation.
Summary Judgment: This paper does not offer a valid, complete, or ethically coherent account of access to kidney transplant evaluation in the US. It selectively defines access, strips it from both biological time and systemic advantage, and then reports descriptive differences without framing, hypothesis, or inference.
If we are to serve the populations we study—not just audit them—we must begin from a place of methodological integrity and moral clarity. This paper fails on both counts.
Recommendation: Rejection.
The topic is critical, but the design and framing must be rethought entirely. A future version, if reconceptualized around true access across the full population spectrum, might merit reconsideration.