Department of Internal Medicine (Trachtenberg), University of Manitoba, Winnipeg, Man.; Departments of Community Health Sciences (Quinn, Ma, Hemmelgarn, Tonelli, Faris, Weaver, Au, Zhang, Manns) and Medicine (Hemmelgarn, Tonelli, Manns), and Libin Cardiovascular Institute of Alberta and O'Brien Institute for Public Health (Hemmelgarn, Tonelli, Manns), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Alberta Health Services (Faris), Calgary, Alta.
CMAJ Open. 2020 Feb 18;8(1):E96-E104. doi: 10.9778/cmajo.20190132. Print 2020 Jan-Mar.
Health care payers are interested in policy-level interventions to increase peritoneal dialysis use in end-stage renal disease. We examined whether increases in physician remuneration for peritoneal dialysis were associated with greater peritoneal dialysis use.
We studied a cohort of patients in Alberta who started long-term dialysis with at least 90 days of preceding nephrologist care between Jan. 1, 2001, and Dec. 31, 2014. We compared peritoneal dialysis use 90 days after dialysis initiation in patients cared for by fee-for-service nephrologists and those cared for by salaried nephrologists before and after weekly peritoneal dialysis remuneration increased from $0 to $32 (fee change 1, Apr. 1, 2002), $49 to $71 (fee change 2, Apr. 1, 2007), and $71 to $135 (fee change 3, Apr. 1, 2009). Remuneration for peritoneal dialysis remained less than hemodialysis until fee change 3. We performed a patient-level differences-in-differences logistic regression, adjusted for demographic characteristics and comorbidities, as well as an unadjusted interrupted time-series analysis of monthly outcome data.
Our cohort included 4262 patients. There was no statistical evidence of a difference in the adjusted differences-indifferences estimator following fee change 1 (0.89, 95% confidence interval [CI] 0.44-1.81), 2 (1.15, 95% CI 0.73-1.83), or 3 (1.52, 95% CI 0.96-2.40). There was no significant difference in the immediate change or the trend over time in peritoneal dialysis use between fee-for-service and salaried groups following any of the fee changes in the interrupted time-series analysis.
We identified no statistical evidence of an increase in peritoneal dialysis use following increased fee-for-service remuneration for peritoneal dialysis. It remains unclear what role, if any, physician payment plays in selection of dialysis modality.
医疗保健支付方对增加终末期肾病患者腹膜透析使用率的政策干预措施很感兴趣。我们研究了提高腹膜透析医生薪酬是否与增加腹膜透析使用率相关。
我们研究了 2001 年 1 月 1 日至 2014 年 12 月 31 日期间在艾伯塔省开始长期透析且在开始透析前至少 90 天接受过肾病医生治疗的患者队列。我们比较了起始透析后 90 天腹膜透析使用率，比较对象为接受按服务收费的肾病医生治疗的患者和接受固定薪酬的肾病医生治疗的患者。在此期间，每周腹膜透析的薪酬从 0 美元增加到 32 美元（第 1 次薪酬变化，2002 年 4 月 1 日），从 49 美元增加到 71 美元（第 2 次薪酬变化，2007 年 4 月 1 日），从 71 美元增加到 135 美元（第 3 次薪酬变化，2009 年 4 月 1 日）。在第 3 次薪酬变化之前，腹膜透析的薪酬一直低于血液透析。我们对患者进行了差异-差异逻辑回归分析，调整了人口统计学特征和合并症，并对每月结果数据进行了未调整的中断时间序列分析。
我们的队列包括 4262 名患者。在第 1 次薪酬变化后，调整后的差异-差异估计值没有统计学意义（0.89，95%置信区间[CI]为 0.44-1.81），第 2 次薪酬变化后也没有统计学意义（1.15，95%CI 为 0.73-1.83），第 3 次薪酬变化后也没有统计学意义（1.52，95%CI 为 0.96-2.40）。在中断时间序列分析中，在任何一次薪酬变化后，在按服务收费组和固定薪酬组之间，腹膜透析使用率的即时变化或随时间的趋势均无显著差异。
我们没有发现增加按服务收费的腹膜透析薪酬后腹膜透析使用率增加的统计证据。医生薪酬在多大程度上（如果有）影响透析模式的选择尚不清楚。
