Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI.
The Centers for Medicare & Medicaid Services, Baltimore, MD.
Med Care. 2022 Mar 1;60(3):240-247. doi: 10.1097/MLR.0000000000001684.
Renal dialysis is a lifesaving but demanding therapy, requiring 3 weekly treatments of multiple-hour durations. Though travel times and quality of care vary across facilities, the extent to which patients are willing and able to engage in weighing tradeoffs is not known. Since 2015, Medicare has summarized and reported quality data for dialysis facilities using a star rating system. We estimate choice models to assess the relative roles of travel distance and quality of care in explaining patient choice of facility.
Using national data on 2 million patient-years from 7198 dialysis facilities and 4-star rating releases, we estimated travel distance to patients' closest facilities, incremental travel distance to the next closest facility with a higher star rating, and the difference in ratings between these 2 facilities. We fit mixed effects logistic regression models predicting whether patients dialyzed at their closest facilities.
Median travel distance was 4 times that in rural (10.9 miles) versus urban areas (2.6 miles). Higher differences in rating [odds ratios (OR): 0.56; 95% confidence interval (CI): 0.50-0.62] and greater area deprivation (OR: 0.50; 95% CI: 0.48-0.53) were associated with lower odds of attending one's closest facility. Stratified models were also fit based on urbanicity. For rural patients, excess travel was associated with higher odds of attending the closer facility (per 10 miles; OR: 1.05; 95% CI: 1.04-1.06). Star rating differences were associated with lower odds of receiving care from the closest facility among urban (OR: 0.57; 95% CI: 0.51-0.63) and rural patients (OR: 0.18; 95% CI: 0.08-0.44).
Most dialysis patients have higher rated facilities located not much further than their closest facility, suggesting many patients could evaluate tradeoffs between distance and quality of care in where they receive dialysis. Our results show that such tradeoffs likely occur. Therefore, quality ratings such as the Dialysis Facility Compare (DFC) Star Rating may provide actionable information to patients and caregivers. However, we were not able to assess whether these associations reflect a causal effect of the Star Ratings on patient choice, as the Star Ratings served only as a marker of quality of care.
肾透析是一种救命但要求苛刻的治疗方法，需要每周进行 3 次长达数小时的治疗。尽管各医疗机构的旅行时间和护理质量存在差异，但患者愿意并能够权衡利弊的程度尚不清楚。自 2015 年以来，医疗保险采用星级评分系统汇总和报告透析设施的质量数据。我们使用来自 7198 家透析机构和 4 星级评级发布的 200 万患者年的全国数据，估计出行距离模型，以评估旅行距离和护理质量在解释患者选择医疗机构方面的相对作用。
我们使用来自 7198 家透析机构和 4 星级评级发布的 200 万患者年的全国数据，估计了患者到最近医疗机构的出行距离、到下一个评级较高的最近医疗机构的增量出行距离，以及这两个机构之间的评级差异。我们拟合了混合效应逻辑回归模型，预测患者是否在其最近的医疗机构进行透析。
中位数出行距离是农村（10.9 英里）与城市（2.6 英里）地区的 4 倍。评级差异较大[比值比（OR）：0.56；95%置信区间（CI）：0.50-0.62]和区域贫困程度较高（OR：0.50；95% CI：0.48-0.53）与较低的到最近医疗机构就诊的几率相关。基于城市性，还拟合了分层模型。对于农村患者，每增加 10 英里，前往更近医疗机构的几率就会增加（OR：1.05；95% CI：1.04-1.06）。在城市（OR：0.57；95% CI：0.51-0.63）和农村（OR：0.18；95% CI：0.08-0.44）患者中，评级差异与从最近医疗机构获得护理的几率较低有关。
大多数透析患者的高评级医疗机构距离其最近的医疗机构并不远，这表明许多患者可能会在距离和护理质量之间权衡利弊，以决定在哪里接受透析。我们的结果表明，这种权衡确实存在。因此，像 Dialysis Facility Compare（DFC）星级评分这样的质量评分可能会为患者和护理人员提供可操作的信息。然而，我们无法评估这些关联是否反映了星级评分对患者选择的因果影响，因为星级评分仅作为护理质量的标志。
