Departments of Population Health Sciences and.
Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.
Clin J Am Soc Nephrol. 2018 Dec 7;13(12):1833-1841. doi: 10.2215/CJN.05680518. Epub 2018 Nov 19.
Peritoneal dialysis is a self-administered, home-based treatment for ESKD associated with equivalent mortality, higher quality of life, and lower costs compared with hemodialysis. In 2011, Medicare implemented a comprehensive prospective payment system that makes a single payment for all dialysis, medication, and ancillary services. We examined whether the prospective payment system increased dialysis facility provision of peritoneal dialysis services and whether changes in peritoneal dialysis provision were more common among dialysis facilities that are chain affiliated, located in nonurban areas, and in regions with high dialysis market competition.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a longitudinal retrospective cohort study of =6433 United States nonfederal dialysis facilities before (2006-2010) and after (2011-2013) the prospective payment system using data from the US Renal Data System, Medicare, and Area Health Resource Files. The outcomes of interest were a dichotomous indicator of peritoneal dialysis service availability and a discrete count variable of dialysis facility peritoneal dialysis program size defined as the annual number of patients on peritoneal dialysis in a facility. We used general estimating equation models to examine changes in peritoneal dialysis service offerings and peritoneal dialysis program size by a pre- versus post-prospective payment system effect and whether changes differed by chain affiliation, urban location, facility size, or market competition, adjusting for 1-year lagged facility-, patient with ESKD-, and region-level demographic characteristics.
We found a modest increase in observed facility provision of peritoneal dialysis and peritoneal dialysis program size after the prospective payment system (36% and 5.7 patients in 2006 to 42% and 6.9 patients in 2013, respectively). There was a positive association of the prospective payment system with peritoneal dialysis provision (odds ratio, 1.20; 95% confidence interval, 1.13 to 1.18) and PD program size (incidence rate ratio, 1.27; 95% confidence interval, 1.22 to 1.33). Post-prospective payment system change in peritoneal dialysis provision was greater among nonurban (<0.001), chain-affiliated (=0.002), and larger-sized facilities (<0.001), and there were higher rates of peritoneal dialysis program size growth in nonurban facilities (<0.001).
Medicare's 2011 prospective payment system was associated with more facilities' availability of peritoneal dialysis and modest growth in facility peritoneal dialysis program size.
This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_11_19_CJASNPodcast_18_12_.mp3.
腹膜透析是一种自我管理的家庭治疗方法，用于治疗与血液透析相关的终末期肾病，其死亡率相当，生活质量更高，成本更低。2011 年，医疗保险实施了一项全面的前瞻性支付制度，为所有透析、药物和辅助服务支付单一费用。我们研究了前瞻性支付制度是否增加了透析机构提供腹膜透析服务的数量，以及腹膜透析提供的变化是否更常见于连锁附属的透析机构、位于非城市地区的透析机构和透析市场竞争激烈的地区的透析机构。
设计、地点、参与者和测量方法：我们使用美国肾脏数据系统、医疗保险和区域卫生资源文件的数据，对 6433 家美国非联邦透析机构进行了前瞻性支付制度前后（2006-2010 年和 2011-2013 年）的纵向回顾性队列研究。我们感兴趣的结果是腹膜透析服务提供的二分指示符和透析机构腹膜透析计划规模的离散计数变量，定义为一个机构中腹膜透析患者的年度数量。我们使用一般估计方程模型，通过前瞻性支付系统前后效果，检查腹膜透析服务提供和腹膜透析计划规模的变化，以及变化是否因连锁附属、城市位置、机构规模或市场竞争而不同，调整了 1 年滞后的机构、终末期肾病患者和地区水平的人口统计学特征。
我们发现，前瞻性支付制度后，观察到的腹膜透析和腹膜透析计划规模有所增加（2006 年为 36%和 5.7 例，2013 年为 42%和 6.9 例）。前瞻性支付制度与腹膜透析提供（优势比，1.20；95%置信区间，1.13 至 1.18）和 PD 计划规模（发病率比，1.27；95%置信区间，1.22 至 1.33）呈正相关。在非城市地区（<0.001）、连锁附属（=0.002）和较大规模的设施（<0.001）中，腹膜透析供应的前瞻性支付系统后变化更大，并且在非城市设施中腹膜透析计划规模的增长率更高（<0.001）。
医疗保险 2011 年的前瞻性支付制度与更多的腹膜透析设施可用性和设施腹膜透析计划规模的适度增长有关。
