Departments of Medicine.
Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, Durham, North Carolina; and.
Clin J Am Soc Nephrol. 2019 Dec 6;14(12):1763-1772. doi: 10.2215/CJN.05910519. Epub 2019 Nov 21.
Peritoneal dialysis (PD) for ESKD is associated with similar mortality, higher quality of life, and lower costs compared with hemodialysis (HD), but has historically been underused. We assessed the effect of the 2011 Medicare prospective payment system (PPS) for dialysis on PD initiation, modality switches, and stable PD use.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Using US Renal Data System and Medicare data, we identified all United States patients with ESKD initiating dialysis before (2006-2010) and after (2011-2013) PPS implementation, and observed their modality for up to 2 years after dialysis initiation. Using logistic regression models, we examined the associations between PPS and early PD experience (any PD 1-90 days after initiation), late PD use (any PD 91-730 days after initiation), and modality switches (PD-to-HD or HD-to-PD 91-730 days after initiation). We adjusted for patient, dialysis facility, and regional characteristics.
Overall, 619,126 patients with incident ESKD received dialysis at Medicare-certified facilities, 2006-2013. Observed early PD experience increased from 9.4% before PPS to 12.6% after PPS. Observed late PD use increased from 12.1% to 16.1%. In adjusted analyses, PPS was associated with increased early PD experience (odds ratio [OR], 1.51; 95% confidence interval [95% CI], 1.47 to 1.55; <0.001) and late PD use (OR, 1.47; 95% CI, 1.45 to 1.50; <0.001). In subgroup analyses, late PD use increased in part due to an increase in HD-to-PD switches among those without early PD experience (OR, 1.59; 95% CI, 1.52 to 1.66; <0.001) and a decrease in PD-to-HD switches among those with early PD experience (OR, 0.92; 95% CI, 0.87 to 0.98; =0.004).
More patients started, stayed on, and switched to PD after dialysis payment reform. This occurred without a substantial increase in transfers to HD.
与血液透析（HD）相比，腹膜透析（PD）用于终末期肾病（ESKD）的死亡率相似，生活质量更高，成本更低，但历史上使用不足。我们评估了 2011 年医疗保险前瞻性支付制度（PPS）对 PD 起始、模式转换和稳定 PD 使用的影响。
设计、设置、参与者和测量：使用美国肾脏数据系统和医疗保险数据，我们确定了所有在 PPS 实施之前（2006-2010 年）和之后（2011-2013 年）开始透析的美国 ESKD 患者，并观察了他们在透析开始后最多 2 年内的治疗模式。我们使用逻辑回归模型，研究了 PPS 与早期 PD 经验（起始后 1-90 天的任何 PD）、晚期 PD 使用（起始后 91-730 天的任何 PD）和模式转换（起始后 91-730 天的 PD 转为 HD 或 HD 转为 PD）之间的关联。我们调整了患者、透析机构和区域特征。
总体而言，2006-2013 年，在医疗保险认证机构接受透析的 619,126 例新发 ESKD 患者中，观察到早期 PD 经验从 PPS 前的 9.4%增加到 PPS 后的 12.6%。观察到晚期 PD 使用从 12.1%增加到 16.1%。在调整后的分析中，PPS 与早期 PD 经验增加相关（比值比[OR]，1.51；95%置信区间[95%CI]，1.47 至 1.55；<0.001）和晚期 PD 使用增加（OR，1.47；95%CI，1.45 至 1.50；<0.001）。亚组分析显示，晚期 PD 使用的增加部分归因于无早期 PD 经验者中 HD 转为 PD 的比例增加（OR，1.59；95%CI，1.52 至 1.66；<0.001）和有早期 PD 经验者中 PD 转为 HD 的比例减少（OR，0.92；95%CI，0.87 至 0.98；=0.004）。
透析支付改革后，更多患者开始、继续并转为 PD 治疗。这一过程并没有导致大量患者转移到 HD。
