Division of Nephrology, University of California San Francisco, San Francisco General Hospital, San Francisco, CA, USA.
BMC Health Serv Res. 2012 Aug 16;12:254. doi: 10.1186/1472-6963-12-254.
In December 2000, Medicare eliminated time limitations in immunosuppressant coverage after kidney transplant for beneficiaries age ≥65 and those who were disabled. This change did not apply to younger non-disabled beneficiaries who qualified for Medicare only because of their end-stage renal disease (ESRD). We sought to examine access to waitlisting for kidney transplantation in a cohort spanning this policy change.
This was a retrospective cohort analysis of 241,150 Medicare beneficiaries in the United States Renal Data System who initiated chronic dialysis between 1/1/96 and 11/30/03. We fit interrupted time series Cox proportional hazard models to compare access to kidney transplant waitlist within 12 months of initiating chronic dialysis by age/disability status, accounting for secular trends.
Beneficiaries age <65 who were not disabled were less likely to be waitlisted after the policy change (hazard ratio (HR) for the later vs. earlier period, 0.93, p = 0.002), after adjusting for sociodemographic factors, co-morbid conditions, income, and ESRD network. There was no evidence of secular trend in this group (HR per year, 1.00, p = 0.989). Likelihood of being waitlisted among those age ≥65 or disabled increased steadily throughout the study period (HR per year, 1.04, p < 0.001), but was not clearly affected by the policy change (HR for the immediate effect of policy change, 0.93, p = 0.135).
The most recent extension in Medicare immunosuppressant coverage appears to have had little impact on the already increasing access to waitlisting among ≥65/ disabled beneficiaries eligible for the benefit but may have decreased access for younger, non-disabled beneficiaries who were not. The potential ramifications of policies on candidacy appeal for access to kidney transplantation should be considered.
2000 年 12 月，医疗保险（Medicare）取消了肾移植后免疫抑制剂覆盖的时间限制，适用于年龄≥65 岁的受益人和残疾受益人。这一变化不适用于因终末期肾病（ESRD）而有资格获得医疗保险但年龄较轻且无残疾的非受益人群体。我们试图在跨越这一政策变化的队列中检查肾移植候补资格的获取情况。
这是一项回顾性队列分析，纳入了美国肾脏数据系统（United States Renal Data System）中 241150 名在 1996 年 1 月 1 日至 2003 年 11 月 30 日期间开始接受慢性透析的 Medicare 受益人。我们使用中断时间序列 Cox 比例风险模型来比较在开始慢性透析后 12 个月内按年龄/残疾状况进入肾移植候补名单的情况，同时考虑到了时间趋势。
未残疾的年龄<65 岁的受益人在政策变更后等待候补名单的可能性较低（与早期相比，晚期的风险比（hazard ratio，HR）为 0.93，p=0.002），调整了社会人口因素、合并症、收入和 ESRD 网络因素后依然如此。该组人群中没有时间趋势的证据（每年的 HR 为 1.00，p=0.989）。在整个研究期间，≥65 岁或残疾的受益人的候补名单可能性稳步增加（每年的 HR 为 1.04，p<0.001），但并未明显受到政策变更的影响（政策变更的即时效应的 HR 为 0.93，p=0.135）。
最近 Medicare 免疫抑制剂覆盖范围的扩大似乎对已经增加的≥65/残疾受益人的候补名单获取机会影响较小，但可能减少了不符合条件的年龄较轻、无残疾受益人的候补名单获取机会。应该考虑政策对候选资格的影响对获取肾移植的影响。
