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

描述(申请人提供)：ESRD PPS包含近30年来首次重大的透析支付政策改革。供应商、制造商和政府监管团体正在从各自的角度看待PPS的影响。目前尚不清楚这些变化将对患者的护理质量产生什么影响，特别是在透析方式方面。在美国，腹膜透析(PD)方式的低使用率降低了为脆弱的ESRD患者提供的护理质量，并为本已财政负担沉重的Medicare ESRD计划增加了相当大的成本。新实施的ESRDS PPS通过增加财政奖励来鼓励提供者增加PD的使用，以采用这种方式，而不是血液透析(HD)。这项拟议研究的目标是确定ESRD支付改革在多大程度上导致了Medicare ESRD计划覆盖的美国透析患者随后使用PD的变化。研究问题。具体地说，我们将解决以下两个目标：1.研究ESRD付费改革对患者在实施ESRD PPS前两年和实施后两年选择透析方式(HD和PD)的影响。2.检查透析方式选择的变化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。OU研究将具体检查是否存在设施组织类型和状态对ESRD PPS的不同影响。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前两年和ESRD PPS后两年的PD使用情况。一个中断的时间序列模型，基于所有ESRD患者开始透析的事件，将被用来评估ESRD PPS在选择透析方式方面的影响。我们将展示PPS前后PD的趋势，并评估PD的变化是否可以归因于ESRD捆绑包。意义重大。国会和美国政府会计办公室呼吁密切监测和评估ESRD捆绑的预期和意外影响。这项研究的发现将通过对预期付款对透析患者弱势人群护理的影响的洞察，具有广泛的公共政策含义。在美国，PD使用率低一直是一个令人担忧的问题，并对患者的护理质量、劳动力参与以及在某些情况下的结果产生不利影响。这项研究还扩展到ESRD之外，并对其他临床领域的大写系统的设计具有影响，因为基于性能的捆绑系统已成为强制实施循证医学、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.