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Leveraging the ESRD Treatment Choices model to understand the benefits of home versus in-center dialysis

利用 ESRD 治疗选择模型了解家庭透析与中心透析的优势

基本信息

批准号：
10733564
负责人：
RICHARD A HIRTH
金额：
$ 67.4万
依托单位：
UNIVERSITY OF MICHIGAN AT ANN ARBOR
依托单位国家：
美国
项目类别：
财政年份：
2023
资助国家：
美国
起止时间：
2023-07-01 至 2027-05-31
项目状态：
未结题

来源：
https://reporter.nih.gov/project-details/10733564
关键词：
Acute Affect Age American Attention Black race Blood Circulation Budgets Caring Chronic Chronic Care Clinical Congestive Heart Failure Controlled Clinical Trials Country Data Diabetes Mellitus Dialysis patients Dialysis procedure Disparity population Educational Models End stage renal failure Ensure Ethnic Origin Goals Health Health Benefit Health Care Costs Healthcare Heart failure Hemodialysis Heterogeneity Hispanic Home Home Hemodialysis Hospital Referrals Housing Infection Investments Kidney Kidney Transplantation Life Low income Measures Medicaid eligibility Medical Medicare Medicare/Medicaid Modality Modeling Organ Outcome Participant Patients Peritoneal Dialysis Peritonitis Physiological Population Procedures Provider Quasi-experiment Random Allocation Renal function Residual state Resources Risk Transplantation Uncertainty United States Uremia black patient care delivery care outcomes comorbidity cost financial incentive health care service utilization hospital utilization improved innovation mortality patient population patient subsets peer preservation social stem time use treatment choice

项目摘要

PROJECT SUMMARY The end stage renal disease (ESRD) population on dialysis is a longstanding challenge to manage. This stems from high health care needs, and comorbidities, with mortality rates 10-fold greater than age- matched controls and costs totaling 7% of Medicare’s budget. In contrast to peer countries, nearly 90% of dialysis in the United States is performed in-center, at a dialysis facility. The reasons for this are often not clinical, but related to financial investments in dialysis facilities, and the lower level of comfort by nephrologists for home dialysis modalities. Many believe that increased use of home dialysis will substantially improve care of the chronic dialysis population, given theoretical physiological advantages (gentler and more continuous), and associations with better survival and lower health care costs. However, the evidence comparing home versus in-center dialysis remains highly controversial given the paucity of controlled clinical trials. Most observational comparisons are plagued by potential issues of selection. Nevertheless, the Center for Medicare & Medicaid Innovation moved forward with the ESRD Treatment Choices (ETC) Model in January 2021, providing robust financial incentives for dialysis centers and nephrologists in randomly selected hospital referral regions to shift dialysis care delivery from the facility to the patient home or to transplantation. Given severe constraints on organ availability for transplantation, this is expected to lead to rapid increases in use of home dialysis. With mandatory and random selection of model participants, there is an unprecedented opportunity to develop less biased assessments of the relative merits of home versus in-center dialysis. First, preservation of residual kidney function and continuous dialysis with home modalities has been proposed to better control uremia and volume overload, conferring a survival benefit and reduced overall healthcare utilization. Second, there are potential trade-offs with use of in-center versus home dialysis that can affect the care of comorbidities that commonly afflict dialysis patients. For example, home modalities may better control heart failure, yet more frequent medical contacts with providers with in-center dialysis may allow early attention to developing issues that can avert acute exacerbations. Third, populations at high social risk (e.g., patients of Black race, dual Medicare-Medicaid eligibles) have lower access to home dialysis, often justified on the basis of poor housing quality and unstable living conditions. It is therefore particularly important to understand whether such patients will realize a net benefit from home dialysis. Leveraging the ETC model’s quasi- experimental design we propose a study with these Aims: 1) To compare overall survival and healthcare spending between ESRD patients on home versus in-center dialysis; 2) To compare outcomes of care for specific comorbidities between ESRD patients on home versus in-center dialysis; 3) To compare clinical outcomes in ESRD patients on home versus in-center dialysis among populations at high social risk.

项目总结