Challenging Assumptions of Outcomes and Costs Comparing Peritoneal and Hemodialysis.
Challenging Assumptions of Outcomes and Costs Comparing Peritoneal and Hemodialysis.
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DOI：
10.1016/j.jval.2021.05.017
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发表时间：
2021-11
期刊：
影响因子：
--
通讯作者：
Lakdawalla D
中科院分区：
文献类型：
--
作者：
Lin E;Lung KI;Chertow GM;Bhattacharya J;Lakdawalla D
政策制定者建议，与血液透析（HD）相比，增加腹膜透析（PD）可以改善终末期肾病（ESKD）的预后，并减少医疗保险支出。我们比较了无保险成人意外ESKD患者PD和HD之间的死亡率、住院率和医疗保险支出。使用工具变量设计，我们利用自然实验鼓励未参保的PD。未参保的患者通常在透析第四个月获得医疗保险。对于那些开始透析的患者，医疗保险覆盖前三个透析月，包括透析开始的日历月的透析前服务。在一个日历月的晚些时候开始透析可以增加透析前的覆盖率，这对于放置PD导管是必不可少的。该政策在本月晚些时候发展ESKD时逐步鼓励PD。透析开始日期似乎与患者特征无关，有效地将患者“随机化”到透析方式，减轻了选择偏差。在该月晚些时候开始透析与PD摄取增加有关：该月晚些时候每周与透析第1天的绝对增加0.8% （95% CI: 0.6%, 0.9%）和透析第12个月的绝对增加0.5% （95% CI: 0.3%, 0.7%）相关。我们观察到PD和HD在12个月的死亡率（- 0.9%,95% CI: - 3.3%, 0.8%）、7-12个月的住院率（- 0.05,95% CI: - 0.20, 0.07）和7-12个月的医疗保险支出（- 702美元，95% CI: - 4,004美元，2,909美元）方面没有显著的绝对差异。在一项工具变量分析中，与HD相比，PD并没有改善预后或降低成本。尽管政策制定者旨在增加家庭透析的使用，但促进家庭透析的政策不太可能改善结果或减少支出。
Policymakers have suggested increasing peritoneal dialysis (PD) would improve end-stage kidney disease (ESKD) outcomes and reduce Medicare spending compared to hemodialysis (HD). We compared mortality, hospitalizations, and Medicare spending between PD and HD among uninsured adults with incident ESKD. Using an instrumental variable design, we exploited a natural experiment encouraging PD among the uninsured. Uninsured patients usually receive Medicare at dialysis month four. For those initiating with PD, Medicare covers the first three dialysis months, including pre-dialysis services in the calendar month of dialysis start. Starting dialysis later in a calendar month increases pre-dialysis coverage essential for PD catheter placements. The policy incrementally encourages PD when developing ESKD later in the month. Dialysis start day appears unrelated to patient characteristics and effectively “randomizes patients” to dialysis modality, mitigating selection bias. Starting dialysis later in the month was associated with increased PD uptake: every week later in the month was associated with an absolute increase of 0.8% (95% CI: 0.6%, 0.9%) at dialysis day 1 and 0.5% (95% CI: 0.3%, 0.7%) at dialysis month 12. We observed no significant absolute difference between PD and HD for 12-month mortality (–0.9%, 95% CI: −3.3%, 0.8%), hospitalizations during months 7–12 (–0.05, 95% CI: −0.20, 0.07), and Medicare spending during months 7–12 (–$702, 95% CI: −$4,004, $2,909). In an instrumental variable analysis, PD did not result in improved outcomes or lower costs compared to HD. Despite an impetus by policymakers aimed at increasing home dialysis use, policies that promote home dialysis are unlikely to improve outcomes or reduce spending.
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