Renal Division and Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
Am J Kidney Dis. 2013 Jun;61(6):947-56. doi: 10.1053/j.ajkd.2012.11.040. Epub 2013 Jan 15.
Launched in January 2011, the prospective payment system (PPS) for the US Medicare End-Stage Renal Disease Program bundled payment for services previously reimbursed independently. Small dialysis organizations may be particularly susceptible to the financial implications of the PPS. The ongoing Study to Evaluate the Prospective Payment System Impact on Small Dialysis Organizations (STEPPS) was designed to describe trends in care and outcomes over the period of PPS implementation. This report details early results between October 2010 and June 2011.
Prospective observational cohort study of patients from a sample of 51 small dialysis organizations.
SETTING & PARTICIPANTS: 1,873 adult hemodialysis and peritoneal dialysis patients.
Secular trends in processes of care, anemia, metabolic bone disease management, and red blood cell transfusions.
Facility-level data are collected quarterly. Patient characteristics were collected at enrollment and scheduled intervals thereafter. Clinical outcomes are collected on an ongoing basis.
Over time, no significant changes were observed in patient to staff ratios. There was a temporal trend toward greater use of peritoneal dialysis (from 2.4% to 3.6%; P = 0.09). Use of cinacalcet, phosphate binders, and oral vitamin D increased; intravenous (IV) vitamin D use decreased (P for trend for all <0.001). Parathyroid hormone levels increased (from 273 to 324 pg/dL; P < 0.001). Erythropoiesis-stimulating agent doses decreased (P < 0.001 for IV epoetin alfa and IV darbepoetin alfa), particularly high doses. Mean hemoglobin levels decreased (P < 0.001), the percentage of patients with hemoglobin levels <10 g/dL increased (from 12.7% to 16.8%), and transfusion rates increased (from 14.3 to 19.6/100 person-years; P = 0.1). Changes in anemia management were more pronounced for African American patients.
Limited data were available for the prebundle period. Secular trends may be subject to the ecologic fallacy and are not causal in nature.
In the period after PPS implementation, IV vitamin D use decreased, use of oral therapies for metabolic bone disease increased, erythropoiesis-stimulating agent use and hemoglobin levels decreased, and transfusion rates increased numerically.
美国医疗保险终末期肾病计划于 2011 年 1 月推出了按项目付费制（PPS），将之前独立报销的服务费用打包付费。小型透析机构可能特别容易受到 PPS 的财务影响。正在进行的评估 PPS 对小型透析机构影响的研究（STEPPS）旨在描述 PPS 实施期间护理和结果的趋势。本报告详细介绍了 2010 年 10 月至 2011 年 6 月期间的早期结果。
对来自 51 个小型透析机构的样本患者进行前瞻性观察队列研究。
1873 名成年血液透析和腹膜透析患者。
护理过程、贫血、代谢性骨病管理和红细胞输注的长期趋势。
每季度收集机构层面的数据。在入组时和随后的预定时间收集患者特征。持续收集临床结果。
随着时间的推移，患者与员工的比例没有明显变化。腹膜透析的使用呈时间趋势（从 2.4%增加到 3.6%；P=0.09）。使用西那卡塞、磷酸盐结合剂和口服维生素 D 的情况增加；静脉（IV）维生素 D 的使用减少（所有趋势 P<0.001）。甲状旁腺激素水平升高（从 273 增加到 324 pg/dL；P<0.001）。促红细胞生成素剂量减少（IV 促红素阿尔法和 IV 达贝泊汀阿尔法的剂量均减少，P<0.001），尤其是高剂量。平均血红蛋白水平下降（P<0.001），血红蛋白水平<10 g/dL 的患者比例增加（从 12.7%增加到 16.8%），输血率增加（从 14.3 增加到 19.6/100 人年；P=0.1）。非洲裔美国患者的贫血管理变化更为明显。
捆绑前时期的数据有限。长期趋势可能受到生态谬误的影响，其性质不是因果关系。
在 PPS 实施后的时期，IV 维生素 D 的使用减少，代谢性骨病的口服治疗使用增加，促红细胞生成素的使用和血红蛋白水平下降，输血率略有增加。
