Impact of Recent Payment Reform on Dialysis Modality Choice among ESRD Patients

描述（由申请人提供）：ESRD PPS包含近30年来透析支付政策的首次重大改革。供应商、制造商和政府监管团体正从各自的角度审视PPS的效果。目前尚不清楚的是，这些变化将对患者的护理质量产生何种影响，特别是在透析方式方面。在美国，腹膜透析（PD）模式的低使用率降低了对易感ESRD患者的护理质量，并增加了本已负担沉重的Medicare ESRD项目的相当大的成本。新实施的ESRDS PPS鼓励提供者通过增加财政激励来增加PD使用，而不是血液透析（HD）。拟议研究的目的是确定ESRD支付改革在多大程度上导致了医疗ESRD计划覆盖的美国透析患者PD使用的后续变化。研究的问题。具体而言，我们将处理以下两个目标：研究在实施ESRD PPS前后两年，ESRD支付改革对患者选择透析方式（HD vs PD）的影响。2. 检查透析方式选择的改变是否与患者的社会人口学和临床特征，和/或透析设施特征有关。我们的研究将特别研究不同类型的设施组织状况是否会对ESRD PPS产生不同的影响。研究设计。我们建议使用美国肾脏疾病系统（USRDS） 2009年1月至2012年12月的数据来评估ESRD PPS前后两年的PD使用情况。基于所有开始透析的ESRD患者的中断时间序列模型将用于评估ESRD PPS对透析方式选择的影响。我们将展示PPS前后PD的趋势，并评估PD的变化是否可归因于ESRD捆绑治疗。的意义。国会和美国政府会计办公室呼吁密切监测和评估ESRD捆绑的预期和非预期影响。本研究的结果将具有广泛的公共政策意义，为透析患者弱势群体的护理提供前瞻性支付的影响。在美国，PD的低使用率引起了人们的关注，并对患者的护理质量、劳动力参与产生了不利影响，在某些情况下，还会影响结果。本研究还扩展到ESRD之外，并对其他临床领域的资本系统设计具有启示意义，因为基于性能的捆绑系统已成为强制执行循证医学、提高护理质量和降低成本的最新方法。

DESCRIPTION (provided by applicant): ESRD PPS contains the first major reform of dialysis payment policy in nearly 30 years. Provider, manufacturer, and government oversight groups are looking at the effect of PPS from their respective viewpoints. What remains unclear is the impact these changes will have on patient quality of care, particularly in the area of dialysis modality. Low use of peritoneal dialysis (PD) modality in the US compromises quality of care delivered to vulnerable ESRD patients and adds considerable cost to an already financially burdened Medicare ESRD program. The newly implemented ESRDS PPS encourages providers to increase PD use by adding financial incentives to adopt that modality as opposed to hemodialysis (HD). The goal of the proposed study is to determine the degree to which the ESRD payment reform has resulted in a subsequent change in PD use among US dialysis patients covered by the Medicare ESRD program. Research Questions. Specifically, we shall address the following two aims: 1. Examine the effects of ESRD payment reform on patient's choice of dialysis modality (HD versus PD) two years before and after the implementation of ESRD PPS. 2. Examine whether changes in dialysis modality choice are associated with patient sociodemographic and clinical characteristics, and/or dialysis facility characteristics. Ou study will specifically examine if there is a differential impact by type of facility organizationa status in response to ESRD PPS. Study Design. We propose to use United States Renal Disease System (USRDS) data from January 2009 through December 2012 to evaluate PD use in the two years before and two years after the ESRD PPS. An interrupted time series model, based on all incident ESRD patients initiating dialysis will be used to assess the impact of the ESRD PPS in the choice of dialysis modality. We will show trends in PD before and after PPS and assess whether changes in PD can be attributed to the ESRD bundle. Significance. Congress and the U.S. Government Accounting Office have called for close monitoring and assessment of both intended and unintended effects of ESRD bundling. Findings from this study will have broad public policy implications by providing insights into the effects of prospective payment on the care of vulnerable population of dialysis patients. The low PD use in the US has been a cause of concern and, adversely impacts patient quality of care, workforce participation, and, in some cases, outcomes. This study also extends beyond ESRD and has implications for design of capitated systems in other clinical areas, as performance-based bundled systems have emerged as the newest approach to mandate evidence-based medicine, enhance quality of care, and reduce costs.