The Effect of Dialysis Chains on Mortality in Patients Receiving Hemodialysis

简介(申请人提供)：背景。由于高死亡率，透析患者的存活率一直是ESRD护理的重点。然而，在过去的15年里，ESRD患者的死亡率并没有得到改善，尽管人们预计技术的进步会提高患者的存活率。根据美国国家糖尿病、消化和肾脏疾病研究所(NIDDK)的数据，美国终末期肾病(ESRD)人群中每年24%的死亡率仍然“高得令人无法接受”。随着终末期肾病患者发病率和患病率的稳步上升，无论是在医学上还是在经济上，它都成为一个更加紧迫的公共卫生问题。目标。绝大多数ESRD患者(超过90%)每周从全国大约4000家获得联邦医疗保险认证的透析机构接受三次血液透析。患者死亡率的显著差异可能受患者病例组合因素和透析设备特性的影响。管理透析护理的设施政策和相关的实践模式，而不是患者特定的原因，一直没有得到充分的研究，可能在影响患者结局方面发挥重要作用。在过去的15年里，大型透析链的巨大增长和巩固引起了人们对许多地区为终末期肾病患者提供的护理质量的担忧。因此，此应用程序旨在1)检查在透析链设施中接受治疗的患者在调整其他设施特征和广泛的患者特征(如人口统计学、临床特征和合并症)后的存活率是更好还是更差；2)评估和比较设施所有权(营利性状态)与链状态对患者死亡率的影响；以及3)检查透析链状态和患者死亡率之间的关系是否可能通过提供者的经济驱动的做法来调节。 方法：研究方法。这项研究将依靠两个主要数据来源：1)美国肾脏数据系统(USRDS)截至2005年12月收集和维护的标准分析文件(SAF)，这是研究人员可获得的最新数据(截至2008年3月)；和2)CMS“透析比较”数据。其他数据来源包括CMS肾脏成本报告数据和2000年美国人口普查数据，以确定邮政编码水平的社会经济特征。这些国家数据库提供了关于美国透析器特征的最全面的信息。多水平回归模型将被用来评估透析链状态对2002年开始门诊血液透析的患者死亡率的影响。意义重大。到目前为止，对于从附属于连锁机构的机构接受透析护理的患者与从非连锁机构接受透析护理的患者之间的患者结果是否存在差异，人们知之甚少。这项拟议研究的潜在结果将揭示设施类型与患者死亡率之间的关系，帮助临床医生和政策制定者确定最佳管理实践，并最终改善ESRD患者的护理和预后。 与公共健康相关：根据美国国家糖尿病、消化和肾脏疾病研究所(NIDDK)的数据，美国终末期肾病(ESRD)人群中每年24%的死亡率仍然高得令人无法接受。随着终末期肾病患者发病率和患病率的稳步上升，无论是在医学上还是在经济上，它都成为一个更加紧迫的公共卫生问题。绝大多数ESRD患者(超过90%)每周从全国大约4000家获得联邦医疗保险认证的透析机构接受3次血液透析。除患者病例组合因素外，患者死亡率的显著差异可能还受到透析设备特性的影响。管理透析护理和相关实践模式的特定机构的政策，而不是患者特定的原因，一直研究不足，可能在影响患者结局方面发挥重要作用。在这个项目中，将研究提供高效透析服务的链条的激增对患者结局和死亡率的影响。这项拟议研究的潜在结果将揭示设施类型与患者死亡率之间的关系，帮助临床医生和政策制定者确定最佳管理实践，并最终改善ESRD患者的护理和预后。

DESCRIPTION (provided by the applicant): Background. Survival among dialysis patients has always been the focus of ESRD care because of the high mortality rate. However, the mortality of ESRD patients has not improved over the past 15 years in spite of improvements in technology that one would expect to improve patient survival. According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the death rate of 24% annually among the ESRD population in the U.S. remains "unacceptably high". With the steady increase in the incidence and prevalence of patients with ESRD, it is becoming an even more urgent public health problem both medically and economically. Objective. The vast majority of ESRD patients (more than 90%) receive hemodialysis three times per week from the nation's roughly 4,000 Medicare-certified dialysis facilities. Substantial differences in patient mortality rate might be influenced by patient case mix factors as well as dialysis facility characteristics. Facilities policies governing dialysis care and associated practice patterns, as opposed to patient-specific causes, have been under-researched and might play an important role in influencing patient outcomes. During the past fifteen years, the tremendous growth and consolidation of large dialysis chains have raised concerns about the quality of care delivered to ESRD patients in many areas. Accordingly, this application seeks to 1) examine whether patients treated in dialysis chain facilities have better or worse survival after adjusting for other facility characteristics and a wide range of patient characteristics such as demographics, clinical characteristics, and comorbidities; 2) evaluate and compare the effect of facility ownership (for-profit status) versus chain status on patient mortality; and 3) examine whether the relationship between dialysis chain status and patient mortality might be mediated through providers' economically driven practices. Methods. The research will rely on two primary sources of data: 1) standard analytical files (SAFs) collected and maintained by the United States Renal Data System (USRDS) as of December 2005, which is the most recent available data for researchers (as of March 2008); and 2) CMS "Dialysis Compare" data. Additional sources of data include CMS Renal Cost Report data and the 2000 US Census data to ascertain ZIP code-level socioeconomic characteristics. These national databases provide the most comprehensive information on the characteristics of dialysis units in the United States. Multilevel regression models will be used to estimate the impact of dialysis chain status on mortality among patients who initiated outpatient hemodialysis in 2002. Significance. To date, little is known regarding whether there are differences in patient outcomes between patients receiving dialysis care from facilities affiliated with chains versus nonchain facilities. The potential findings of the proposed study will shed new light on the relationship between type of facility and patient mortality, aid clinicians and policy makers in identifying optimal management practices, and eventually improve care and outcomes of ESRD patients. PUBLIC HEALTH RELEVANCE: According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the death rate of 24% annually among the end-stage renal disease (ESRD) population in the U.S. remains "unacceptably high." With the steady increase in the incidence and prevalence of patients with ESRD, it is becoming an even more urgent public health problem both medically and economically. The vast majority of ESRD patients (more than 90%) receive hemodialysis 3 times per week from the nation's roughly 4,000 Medicare-certified dialysis facilities. Substantial differences in patient mortality rate might be influenced by dialysis facility characteristics in addition to patient case mix factors. Facility-specific policies governing dialysis care and associated practice patterns, as opposed to patient-specific causes, have been under-researched and might play an important role in influencing patient outcomes. In this project, the proliferation of chains providing efficient dialysis services will be examined with regard to their influence on patient outcomes and mortality. The potential findings of the proposed study will shed new light on the relationship between type of facility and patient mortality, aid clinicians and policy makers in identifying optimal management practices, and eventually improve care and outcomes of ESRD patients.