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

项目摘要 背景：2017年影响74.6万美国人的终末期肾病(ESRD)是最后阶段 除非启动肾脏替代疗法，否则会导致死亡。治疗的结果 可供选择(中心内血液透析、家庭透析、肾移植)，移植是 首选方式，提供最好的生存时间、生活质量和最低的平均成本。家 透析方式也比中心内透析成本更低，并与提高患者满意度有关。 尽管有这些优点，15%的终末期肾病患者接受了家庭透析或活体供肾。 2016年移植，只有14%的患者加入了移植等待名单或在一次移植内接受了移植 开始治疗的年份。推进中的美国肾脏健康倡议(2019年7月)提议登记 50%的ESRD护理提供者采用共享风险替代支付模式(APM)，这将使提供者的 支付节省的保健服务使用费用，目的是增加使用具有成本效益的治疗 (家庭透析和移植)。目前，没有证据表明肾病学家参与了急性呼吸暂停综合征，或 它们对专科护理中的治疗结果的影响。这项研究将检查两个肾病科医生的参与 共同风险APM(责任护理组织和ESRD无缝护理组织[ESCO])； APM相关肾病专科医生群体特征及对肾科专科医生APM的影响 新发终末期肾病患者的治疗使用和临床结果的从属关系。数据：此项目将链接 11年(2006-2017)美国肾脏疾病系统数据-丰富的临床和管理数据 &gt；1,250,000名ESRD事件患者和&>7,500家透析设备-到提供者级别的ACO(Medicare)数据 共享储蓄计划提供商级别的文件)和ESCO参与(提供商级别的公共数据)。几个 其他公共数据集(例如，美国人口普查局、CMS医院比较)将补充提供商- 具有设施和社区特征的级别数据集。分析：AIM 1将测试APM之间的关联 应用LOGISTICS对肾病学家的主要地理、社会人口学和设施特征进行分析 回归模型。目标2将评估肾内科医生参与APM对治疗使用和 使用严格的准实验方法(差异法)得出的ESRD患者的健康结果 回归)，比较肾科医生在加入APM前后的治疗使用情况和患者的结果， 在11年的研究中，从未有关联的肾病学家的这些结果相对于当代的变化 APM被广泛采用的时期。影响：一半的ESRD护理将强制参加APM 供应商在2020年。这项研究将提供有关肾病学家的基础信息 到目前为止，APM的从属关系以及APM从属关系对#年的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 关于在特殊护理环境中设计和实施APM的思考。

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.