Impact of Randomized Payment Incentives on Disparities in Home Dialysis and Kidney Transplantation

随机支付激励对家庭透析和肾移植差异的影响

• 批准号: 10569582
• 负责人: Rachel E Patzer
• 金额: $ 66.05万
• 依托单位: BROWN UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-02-09 至 2026-11-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10569582
• 关键词: Address; Adult; American; Area; Caring; Clinical Data; Control Groups; Dialysis procedure; Disadvantaged; Disparity; Donor person; End stage renal failure; Equity; Ethnic Origin; Evaluation; Goals; Health; Health Services Accessibility; Hemodialysis; Home; Hour; Incentives; Insurance; Insurance Coverage; Kidney; Kidney Diseases; Kidney Failure; Kidney Transplantation; Lead; Life; Measurement; Measures; Medicaid; Medicare; Medicare/Medicaid; Minority; Modeling; Neighborhoods; Observational Study; Outcome; Patients; Performance; Policies; Policy Maker; Population; Provider; Quality of Care; Quality of life; Race; Random Allocation; Randomized; Registries; Resources; Risk; Risk Factors; Testing; Transplantation; Treatment Failure; United States Centers for Medicare and Medicaid Services; Waiting Lists; Work; access disparities; cost; effective therapy; ethnic disparity; ethnic minority; ethnic minority population; financial incentive; flexibility; health equity; improved; innovation; mortality; neighborhood disadvantage; novel; payment; primary outcome; programs; racial disparity; racial minority; racial minority population; safety net; social; social disparities; socioeconomic disparity; transplant centers; treatment choice

PROJECT SUMMARY Kidney failure is a life-threatening condition that disproportionately impacts the most socially disadvantaged communities in the US. Approximately 88% of patients with kidney failure initiate hemodialysis treatment, where in-center care typically requires thrice-weekly treatments lasting 3-4 hours. Alternatives to in-center hemodialysis include kidney transplantation, which is associated with lower mortality and improved quality of life, and home dialysis, which has comparable outcomes to hemodialysis but is associated with lower costs and offers greater flexibility and independence for patients. But these treatments are substantially underused, and persistent racial disparities have been documented in receipt of home dialysis and in all steps leading to transplantation. In January 2021, the Centers for Medicare and Medicaid Services (CMS) initiated the End- stage Renal Disease Treatment Choices (ETC) Model. This mandatory model – the first of its kind – randomly assigned dialysis facilities and managing clinicians in 30% of the US to receive financial incentives to increase rates of home dialysis and kidney transplantation. Some observational studies suggest that payment incentives may increase home dialysis, but causal evidence is lacking, and the impact of payment reforms on equity in kidney failure treatments remains unclear. More broadly, CMS and other payers have advanced value-based payment policies to improve quality of care, but evaluations of these strategies have been hampered by the absence of appropriate control groups, often due to uniform policy implementation across the U.S. Further, value-based payments may inadvertently lead to increasing disparities in access to care if safety-net and minority-serving providers have fewer resources to respond to performance incentives, or if performance measures fail to account for patients' social risk. This proposal will test the hypothesis that although the ETC Model will increase home dialysis and referral/evaluation for transplantation, it will also widen disparities in these outcomes because facilities that disproportionately serve minority and socially disadvantaged patients will make lower performance gains and will be more likely to receive financial penalties. Our specific aims are: 1. Examine the impact of the ETC Model on the use of home dialysis and racial/ethnic and socioeconomic disparities in home dialysis, 2. Identify the effects of the ETC Model on disparities in access to kidney transplantation and 3. Examine consequences of the ETC Model for dialysis facilities according to their patients' social risk. The proposal is innovative, as we leverage an unprecedented randomized payment reform to estimate causal effects of financial incentives on disparities for a high-cost, high-need population. We will derive neighborhood disadvantage by geocoding patient addresses and maximize the comprehensiveness of our evaluation by including patients who lack traditional Medicare coverage. Thus, this work will provide rigorous, causal evidence about the health equity implications of one of the largest randomized tests of payment reform ever conducted in the U.S.

项目摘要 肾衰竭是一种危及生命的疾病，对社会上最弱势的人影响不成比例 美国的社区。大约88%的肾衰竭患者开始血液透析治疗， 其中中心护理通常需要每周三次治疗，持续3-4小时。替代中心 血液透析包括肾移植，其与较低死亡率和改善的血液透析质量相关。 生活和家庭透析，其结果与血液透析相当，但费用较低 并为患者提供更大的灵活性和独立性。但这些治疗方法基本上没有得到充分利用， 在接受家庭透析和导致透析的所有步骤中， 移植2021年1月，医疗保险和医疗补助服务中心（CMS）启动了结束- 阶段肾病治疗选择（ETC）模型。这种强制性的模式-第一种-随机 在美国30%的地区分配透析设施和管理临床医生，以获得经济激励， 家庭透析和肾移植的比率。一些观察性研究表明， 可能会增加家庭透析，但缺乏因果关系的证据，以及支付改革对公平性的影响， 肾衰竭的治疗仍不清楚。更广泛地说，CMS和其他支付者已经实现了基于价值的先进 支付政策，以提高护理质量，但这些战略的评估受到阻碍， 缺乏适当的控制组，往往是由于统一的政策实施在美国此外， 基于价值的支付可能会无意中导致在获得医疗服务方面的差距扩大， 服务少数群体的供应商有较少的资源来应对业绩激励，或者如果业绩 措施未能顾及病人的社会风险。这一提议将检验一个假设，即虽然ETC 该模式将增加家庭透析和转诊/移植评估，也将扩大 这些结果是因为不成比例地服务于少数民族和社会弱势患者的设施 将获得较低的性能增益，并且更有可能受到经济处罚。我们的具体目标是： 1.检查ETC模型对家庭透析使用以及种族/民族和社会经济的影响 家庭透析的差异，2.确定ETC模型对肾脏获取差异的影响 移植; 3.检查ETC模型对透析设施的影响， 患者的社会风险。这项提议是创新的，因为我们利用了前所未有的随机支付改革 估计财政激励措施对高成本、高需求人口的不平等的因果影响。我们将 通过对患者地址进行地理编码，得出邻近地区的劣势，并最大限度地提高 我们的评估包括缺乏传统医疗保险覆盖的患者。因此，这项工作将提供 严格的，因果关系的证据，关于健康公平的影响，一个最大的随机测试， 最大的一次支付改革。