Facility Practice Variation to Help Understand the Effects of Public Policy: Insights from the Dialysis Outcomes and Practice Patterns Study (DOPPS)
Facility Practice Variation to Help Understand the Effects of Public Policy: Insights from the Dialysis Outcomes and Practice Patterns Study (DOPPS)
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DOI：
10.2215/cjn.03930416
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发表时间：
2017-01-01
影响因子：
9.8
通讯作者：
Robinson, Bruce M.
中科院分区：
文献类型：
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作者：
Fuller, Douglas S.;Robinson, Bruce M.
最近的医疗保险和医疗补助服务中心政策使用透析设施实践变化来制定公共评级和调整支付。在透析机构比较星星评级系统（DFC SRS）中，基于性能的临床指标的机构相对死亡率变化近两倍（标准化死亡率;第10/90季度：0.71，1.34）和住院（标准化住院率;第10/90位患者：0.64，1.37），输血几乎是四倍（标准化输血比率;第10/90次输血：0.43，1.65）。医疗保险索赔数据（自2014年7月起）表明，6个月内接受血液透析住院（第10/90个月：27%，50%）和输血（第10/90个月：3%，17%）的患者比例的设施变化远远超过最近相对温和的总体纵向趋势。对于瘘管（第10/90次随访：50%，78%）和导管使用>90天（第10/90次随访：3%，19%），DFC SRS评级的设施变化也很大。相比之下，成人血液透析Kt/V>1.2（第10/90次随访：84%，97%）和总血清钙>10.2 mg/dl（中位数，1%;第75/90次随访：3%，5%）的DFC SRS评级机构分布相当狭窄，可能具有可疑价值。同样，在美国透析结局和实践模式研究中，机构血清甲状旁腺激素中位数的变化超过2倍（第10/90次免疫：290 pg/ml，629 pg/ml）和铁蛋白（第10/90季度：469 ng/ml，1143 ng/ml）水平，机构平均治疗时间变化30分钟（第10/90届奥运会：204分钟，234分钟）。血清甲状旁腺激素和铁蛋白水平升高，以及透析治疗时间通常较短，代表了现有政策未检查的领域;这些值的总体趋势和设施变化可能反映了政策或报销压力的非预期后果，因此引起关注。此外，从晚期CKD到透析的过渡期的结局仍然很差，该领域的政策举措和绩效问责制仍然不足。需要在晚期CKD和早期透析阶段建立更容易接受政策监督的创新综合护理模式。总而言之，设施变化通常大于当前的纵向趋势，不应忽视。具有国家代表性的观测数据库（例如，透析结果和实践模式研究）和ESRD登记可以为决策者提供额外的工具来评估设施变化、制定政策和监测非预期影响。
Recent Centers for Medicare & Medicaid Services policies have used dialysis facility practice variation to develop public ratings and adjust payments. In the Dialysis Facility Compare star rating system (DFC SRS), facility-relative rates of performance-based clinical measures varied nearly two-fold for mortality (standardized mortality ratio; 10th/90th percentiles: 0.71, 1.34) and hospitalization (standardized hospitalization ratio; 10th/90th percentiles: 0.64, 1.37), and nearly four-fold for transfusion (standardized transfusion ratio; 10th/90th percentiles: 0.43, 1.65). Medicare claims data (from July of 2014) demonstrate that facility variation for the proportions of patients on hemodialysis hospitalized (10th/90th percentiles: 27%, 50%) and transfused (10th/90th percentiles: 3%, 17%) within 6 months that far exceeds relatively modest recent overall longitudinal trends. DFC SRS rated facility variation is also substantial for fistula (10th/90th percentiles: 50%, 78%) and catheter use >90 days (10th/90th percentiles: 3%, 19%). By contrast, DFC SRS rated facility distributions for adult hemodialysis Kt/V>1.2 (10th/90th percentiles: 84%, 97%) and total serum calcium >10.2 mg/dl (median, 1%; 75th/90th percentiles: 3%, 5%) are quite narrow and may be of questionable value. Likewise, variation in the US Dialysis Outcomes and Practice Patterns Study is over two-fold for facility median serum parathyroid hormone (10th/90th percentiles: 290 pg/ml, 629 pg/ml) and ferritin (10th/90th percentiles: 469 ng/ml, 1143 ng/ml) levels, and facility mean treatment time varies by 30 minutes (10th/90th percentiles: 204 minutes, 234 minutes). Rising serum parathyroid hormone and ferritin levels, and generally short dialysis treatment time, represent areas unchecked by existing policy; both overall trends and facility variation in these values may reflect unintended consequences of policy or reimbursement pressures and therefore raise concern. Additionally, outcomes in the transition period from advanced CKD to dialysis remain poor, and policy initiatives and performance accountability in this area remain insufficient. Innovative models of comprehensive care in advanced CKD and the early dialysis period which are more amenable to policy oversight are needed. In summary, facility variation is typically larger than prevailing longitudinal trends, and should not be overlooked. The combination of nationally representative observational databases (e.g., the Dialysis Outcomes and Practice Patterns Study) and ESRD registries can provide policy makers with additional tools to evaluate facility variation, develop policies, and monitor unintended effects.