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

• 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
• 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

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.

项目摘要 透析上的末期肾脏疾病（ESRD）人群是一个长期以来的管理挑战。这 源于高度医疗保健需求和合并症，死亡率大于年龄的10倍 - 匹配的控制和成本总计占医疗保险预算的7％。与同行国家相反，几乎有90％ 透析在透析设施中进行中心进行。原因通常不是 临床，但与透析设施的金融投资有关，以及较低的舒适度 家庭透析方式的肾脏科医生。许多人认为，增加家庭透析的使用将 鉴于理论生理优势，大大改善了慢性透析人群的护理 （更温和，更连续），并与更好的生存和较低的医疗保健成本保持联系。 但是，鉴于有一个比较家庭与中心透析的证据仍然存在很大争议 对照临床试验的缺乏。大多数观察性比较都受到潜在问题的困扰 选择。尽管如此，Medicare＆Medicaid Innovation中心与ESRD一起前进 2021年1月的治疗选择（ETC）模型，为透析中心提供了强大的经济激励措施 随机选择的医院转诊区域中的肾脏病医生将透析护理从 病人家或移植的设施。给定对器官可用性的严重限制 移植，预计这将导致家庭透析的使用迅速增加。与强制性和 随机选择模型参与者，存在前所未有的机会来发展较少的偏见 评估家庭与中心透析的相对优点。首先，保存残留肾脏 提出了具有家庭方式的功能和连续透析，以更好地控制尿素和 批量超负荷，会议的生存益处，并减少了整体医疗保健利用。第二，有 使用中心与家庭透析的潜在权衡可能会影响合并症的护理 通常受苦透析患者。例如，家庭方式可以更好地控制心力衰竭，但更多 与提供者的医疗接触经常与中心透析的提供者可能会允许早期关注 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，符合双重医疗保险 - 医学辅助工具）的透析范围较低，通常是合理的 住房质量不佳和不稳定的生活条件。因此，了解 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项针对这些目的的研究：1）比较总体生存和医疗保健 ESRD患者在家庭中与中心透析之间的支出； 2）比较护理的结果 ESRD患者与中心透析的ESRD患者之间的特定合并症； 3）比较临床 ESRD患者在家庭中与中心透析的ESRD患者的成果在高度社会风险中。