Impact of alternative payment models on specialist care for patients with new-onset end-stage renal disease

项目摘要 背景：终末期肾病（ESRD）是2017年影响超过746，000名美国人的最后阶段， 慢性肾脏疾病，导致死亡，除非肾脏替代治疗开始。治疗 可用的选择（中心血液透析，家庭透析，肾移植），移植是 首选的方式，提供最佳的生存时间，生活质量的结果，和最低的平均成本。家 透析方式也比中心透析便宜，并且与提高的患者满意度相关。 尽管有这些优势，但<15%的ESRD患者接受了家庭透析或活体供肾 在2016年的移植中，只有14%的患者加入了移植等待名单或在一年内接受了移植。 开始治疗的年份。推进美国肾脏健康倡议（2019年7月）建议招募 50%的ESRD护理提供者采用风险分担替代支付模式（APM）， 支付保健服务使用的费用节省，目的是增加使用具有成本效益的治疗 (home透析和移植）。目前，没有证据表明肾病学家参与了APM，或 它们对专科护理治疗结果的影响。这项研究将检查肾脏科医生参与两个 风险分担APM（责任护理组织[ACO]和ESRD无缝护理组织[ESCO]）， 描述APM附属肾病学家人群的特征，并估计肾病学家APM的影响 新发ESRD患者的治疗使用和临床结局之间的关系。数据：该项目将连接 11年（2006-2017）美国肾脏疾病系统数据丰富的临床和管理数据， > 1，250，000例ESRD患者和> 7，500家透析机构-ACO（医疗保险）提供者级数据 共享储蓄计划提供商级文件）和共享储蓄计划参与（提供商级公共数据）。几 附加的公共数据集（例如，美国人口普查局，CMS医院比较）将补充供应商- 具有设施和社区特征的水平数据集。分析：目标1将测试APM之间的关联 使用Logistic回归分析的关系和肾病学家的关键地理、社会人口和设施特征 回归模型目标2将评估肾病学家APM参与对治疗使用的影响， 使用严格的准实验方法（差异中的差异）评估ESRD患者的健康结局 回归），比较APM加入前后肾病学家的治疗使用和患者的结局， 相对于11年期间从未隶属的肾病学家中这些结果的当代变化， 广泛采用APM的时期。影响：对于一半的ESRD护理，APM参与将是强制性的 供应商在2020年。这项研究将提供有关肾病学家的基础信息， 以及加入APM对治疗使用和健康结果的影响， 新发ESRD患者。重要的是，这项研究的发现将为更广泛的政策和卫生系统提供信息。 在专科护理环境中设计和实施APM的审议。

Project Summary Background: End-stage renal disease (ESRD), which affected >746,000 Americans in 2017, is the final stage of chronic kidney disease, leading to death unless renal replacement therapy is initiated. Of the treatment options available (in-center hemodialysis, home dialysis, kidney transplantation), transplantation is the preferred modality, offering the best survival time, quality of life outcomes, and lowest average cost. Home dialysis modalities are also less costly than in-center dialysis and associated with improved patient satisfaction. Despite these advantages, <15% of incident ESRD patients received home dialysis or a living donor kidney transplant in 2016, and only 14% of patients joined a transplant waiting list or received a transplant within one year of initiating treatment. The Advancing American Kidney Health initiative (July 2019) proposes to enroll 50% of ESRD care providers in a shared-risk alternative payment model (APM) that would tie providers' payment to cost savings on health service use, with the goal of increasing use of cost-effective treatments (home dialysis and transplantation). Currently, no evidence exists about nephrologist participation in APMs, or their impact on treatment outcomes in specialty care. This study will examine nephrologist participation in two shared-risk APMs (accountable care organizations [ACOs] and ESRD seamless care organizations [ESCOs]), to characterize the population of APM-affiliated nephrologists and estimate the impact of nephrologist APM affiliation on treatment use and clinical outcomes for patients with new-onset ESRD. Data: This project will link 11 years (2006-2017) of United States Renal Disease System data—rich clinical and administrative data for >1,250,000 incident ESRD patients and >7,500 dialysis facilities—to provider-level data on ACO (Medicare Shared Savings Program Provider-level files) and ESCO participation (provider-level public data). Several additional public data sets (e.g., US Census Bureau, CMS Hospital Compare) will supplement the provider- level dataset with facility and community characteristics. Analysis: Aim 1 will test associations between APM affiliation and nephrologists' key geographic, sociodemographic, and facility characteristics using logistic regression models. Aim 2 will estimate the impact of nephrologist APM participation on treatment use and ESRD patient health outcomes using rigorous quasi-experimental methods (difference-in-difference regression), comparing nephrologists' treatment use and patients' outcomes before and after APM affiliation, relative to contemporary changes in these outcomes among never-affiliated nephrologists during an 11-year period of widespread APM adoption. Implications: APM participation will be mandatory for half of ESRD care providers in 2020. This research will provide foundational information about nephrologists that have been affiliated with APMs to date and about the impact of APM affiliation on treatment use and health outcomes for patients with new-onset ESRD. Importantly, this study's findings will inform broader policy and health systems deliberations about the design and implementation of APMs in specialty care settings.