The Association of Dialysis Facility Payer Mix With Access to Kidney Transplantation.
The Association of Dialysis Facility Payer Mix With Access to Kidney Transplantation.
复制标题
透析设施付款人的关联与获得肾脏移植的混合。
DOI：
10.1001/jamanetworkopen.2023.22803
复制
发表时间：
2023-07-03
影响因子：
13.8
通讯作者：
Adler, Joel T.
中科院分区：
文献类型：
--
作者：
Cron, David C.;Tsai, Thomas C.;Patzer, Rachel E.;Husain, Syed A.;Xiang, Lingwei;Adler, Joel T.
透析设施级别的商业付款人组合是否与患者获得肾移植有关？在这项包括2323003名接受意外透析的患者的队列研究中，患者层面的商业保险与1年内肾移植等待名单增加相关，但机构层面的商业付款人组合与等待名单没有显著的独立关联。这些发现表明，虽然患者的保险状况与获得肾移植有关，但透析设施付款人组合本身与等待名单无关；然而，随着透析保险覆盖范围的发展，应该监测对获得肾移植的潜在下游影响。本队列研究评估了透析机构级商业付款人组合与1年患者等待肾移植发生率的关系。终末期肾病患者的保险覆盖范围已经转向更多的透析机构的商业保险患者。保险状况、医疗机构级别的付款人组合和获得肾移植之间的关系尚不清楚。确定透析机构商业付款人组合与1年肾移植等待名单发生率的关系，并描述患者与机构层面的商业保险的关系。这项基于人群的回顾性队列研究使用了2013年至2018年美国肾脏数据系统的数据。参与者包括2013年至2017年期间开始慢性透析的18至75岁患者，不包括既往肾移植或有肾移植主要禁忌症的患者。数据分析时间为2021年8月至2023年5月。透析机构商业支付者组合，按每个机构有商业保险的患者比例计算。主要结局是患者在透析开始后1年内被列入肾移植等待名单。采用多变量Cox回归，剔除死亡因素，调整患者水平（人口统计学、社会经济和医疗）和设施水平因素。6565家医院共有23303例患者符合纳入标准，其中97617例（41.9%）为女性，平均[SD]年龄为58.0[12.1]岁。参与者包括70 062名黑人患者（30.1%）、42 820名西班牙裔患者（18.4%）、105 368名白人患者（45.2%）和14 753名（6.3%）其他种族或民族患者（如美国印第安人或阿拉斯加原住民、亚洲人、夏威夷原住民或太平洋岛民，以及多种族）。在6565家透析机构中，平均（SD）商业支付者比例为21.2%（15.6个百分点）。患者层面的商业保险与排队等候的发生率增加相关（校正风险比[aHR]， 1.86; 95% CI, 1.80-1.93; P < .001）。在机构层面和协变量调整前，较高的商业付款人组合与等待名单增加相关（第四与第一付款人组合四分位数[Q]: HR， 1.79; 95% CI, 1.67-1.91; P < .001）。然而，在协变量调整后，包括调整患者水平的保险状态，商业付款人组合与结果没有显著相关（第四季度vs第一季度：aHR， 1.02; 95% CI, 0.95-1.09; P = 0.60）。在这项针对新开始接受慢性透析的患者的全国性队列研究中，尽管患者级别的商业保险与更高的肾移植等待名单相关，但机构级别的商业付款人组合与患者被添加到移植等待名单中没有独立的关联。随着透析保险覆盖范围的发展，应该监测对获得肾移植的潜在下游影响。
Is dialysis facility–level commercial payer mix associated with patient access to kidney transplant? In this cohort study including 233 003 patients receiving incident dialysis, commercial insurance at the patient-level was associated with increased wait-listing for kidney transplant within 1 year, but there was no significant independent association of facility-level commercial payer mix with wait-listing. These findings suggest that while patient insurance status was associated with access to kidney transplant, dialysis facility payer mix did not itself have an association with wait-listing; nevertheless, as the landscape of insurance coverage for dialysis evolves, the potential downstream impact on access to kidney transplant should be monitored. This cohort study assesses the association of dialysis facility–level commercial payer mix with 1-year incidence of patient wait-listing for kidney transplant. Insurance coverage for patients with end-stage kidney disease has shifted toward more commercially insured patients at dialysis facilities. The associations among insurance status, facility-level payer mix, and access to kidney transplantation are unclear. To determine the association of dialysis facility commercial payer mix and 1-year incidence of wait-listing for kidney transplantation, and to delineate the association of commercial insurance at the patient vs facility level. This retrospective population-based cohort study used data from the United States Renal Data System from 2013 to 2018. Participants included patients aged 18 to 75 years initiating chronic dialysis between 2013 and 2017, excluding patients with a prior kidney transplant or with major contraindications to kidney transplant. Data were analyzed from August 2021 and May 2023. Dialysis facility commercial payer mix, calculated as the proportion of patients with commercial insurance per facility. The primary outcome was patients added to a waiting list for kidney transplant within 1 year of dialysis initiation. Multivariable Cox regression, censoring for death, was used to adjust for patient-level (demographic, socioeconomic, and medical) and facility-level factors. A total of 233 003 patients (97 617 [41.9%] female patients; mean [SD] age, 58.0 [12.1] years) across 6565 facilities met inclusion criteria. Participants included 70 062 Black patients (30.1%), 42 820 Hispanic patients (18.4%), 105 368 White patients (45.2%), and 14 753 patients (6.3%) who identified as another race or ethnicity (eg, American Indian or Alaskan Native, Asian, Native Hawaiian or Pacific Islander, and multiracial). Of 6565 dialysis facilities, the mean (SD) commercial payer mix was 21.2% (15.6 percentage points). Patient-level commercial insurance was associated with increased incidence of wait-listing (adjusted hazard ratio [aHR], 1.86; 95% CI, 1.80-1.93; P < .001). At the facility-level and before covariate adjustment, higher commercial payer mix was associated with increased wait-listing (fourth vs first payer mix quartile [Q]: HR, 1.79; 95% CI, 1.67-1.91; P < .001). However, after covariate-adjustment, including adjusting for patient-level insurance status, commercial payer mix was not significantly associated with outcome (Q4 vs Q1: aHR, 1.02; 95% CI, 0.95-1.09; P = .60). In this national cohort study of patients newly initiated on chronic dialysis, although patient-level commercial insurance was associated with higher access to the kidney transplant waiting lists, there was no independent association of facility-level commercial payer mix with patients being added to waiting lists for transplant. As the landscape of insurance coverage for dialysis evolves, the potential downstream impact on access to kidney transplant should be monitored.
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影响因子：
4.2
作者：
Plantinga L;Pastan S;Kramer M;McClellan A;Krisher J;Patzer RE
通讯作者：
Patzer RE
影响因子：
16.9
作者：
Killian, A. Cozette;Shelton, Brittany;Locke, Jayme E.
通讯作者：
Locke, Jayme E.
DOI：
10.1016/j.jamcollsurg.2016.07.004
发表时间：
2016-10-01
影响因子：
5.2
作者：
DuBay, Derek A.;MacLennan, Paul A.;Locke, Jayme E.
通讯作者：
Locke, Jayme E.
影响因子：
120.7
作者：
Nguyen, Kevin H.;Oh, Eunhae G.;Trivedi, Amal N.
通讯作者：
Trivedi, Amal N.
DOI：
10.2202/1547-7355.1792
发表时间：
2011-01-01
影响因子：
0.8
作者：
Flanagan, Barry E.;Gregory, Edward W.;Lewis, Brian
通讯作者：
Lewis, Brian