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

项目摘要 接受透析的终末期肾病（ESRD）人群是一项长期的管理挑战。这 源于高医疗保健需求和合并症，死亡率是年龄的10倍， 与医疗保险预算的7%相匹配的控制和成本。与其他国家相比，近90%的 在美国，透析是在透析机构的中心内进行的。原因往往不是 临床，但与透析设施的财政投资有关， 肾科医生的家庭透析模式。许多人认为，增加家庭透析的使用将 鉴于理论上的生理优势，大幅改善慢性透析人群的护理 （更温和，更持续），以及与更好的生存和更低的医疗保健成本的关联。 然而，比较家庭与中心透析的证据仍然存在很大争议， 缺乏对照临床试验。大多数观测比较都受到潜在问题的困扰， 选择.尽管如此，医疗保险和医疗补助创新中心继续推进ESRD 2021年1月的治疗选择（ETC）模型，为透析中心提供强大的财务激励 和肾脏科医生在随机选择的医院转诊地区， 患者的家庭或移植。鉴于器官供应的严重限制， 移植，这预计将导致家庭透析的使用迅速增加。强制性和 随机选择模型参与者，有一个前所未有的机会，发展少偏见 家庭透析与中心透析的相对优点评估。第一，保留残肾 已经提出了使用家庭模式进行功能和连续透析以更好地控制尿毒症， 容量超负荷，带来生存益处并降低整体医疗保健利用。二是 使用中心透析与家庭透析的潜在权衡，可能影响合并症的治疗， 通常折磨透析患者。例如，家庭模式可以更好地控制心力衰竭，但更多地 与中心透析提供者的频繁医疗接触可能会使早期注意到 可以避免急性加重的问题。第三，社会风险高的人群（例如，黑人患者 种族，双重医疗保险-医疗补助计划）获得家庭透析的机会较少，通常基于以下理由 住房质量差，居住条件不稳定。因此，了解以下情况尤为重要： 这些患者是否会从家庭透析中获得净收益。利用ETC模型的准- 实验设计我们提出了一个研究与这些目的：1）比较总生存率和医疗保健 ESRD患者在家中与中心透析之间的花费; 2）比较 接受家庭透析与中心透析的ESRD患者之间的特定合并症; 3）比较临床 高社会风险人群中接受家庭与中心透析的ESRD患者的结局。

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.