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Peritoneal Dialysis Patient Outcomes under the Medicare Expanded Dialysis Prospective Payment System.

Authors
  • Young, Eric W1, 2
  • Kapke, Alissa3
  • Ding, Zhechen3
  • Baker, Regina2
  • Pearson, Jeffrey3
  • Cogan, Chad3
  • Mukhopadhyay, Purna3
  • Turenne, Marc N3
  • 1 Arbor Research Collaborative for Health, Ann Arbor, Michigan; and [email protected]
  • 2 University of Michigan, Ann Arbor, Michigan.
  • 3 Arbor Research Collaborative for Health, Ann Arbor, Michigan; and.
Type
Published Article
Journal
Clinical Journal of the American Society of Nephrology
Publisher
American Society of Nephrology
Publication Date
Oct 07, 2019
Volume
14
Issue
10
Pages
1466–1474
Identifiers
DOI: 10.2215/CJN.01610219
PMID: 31515234
Source
Medline
Keywords
Language
English
License
Unknown

Abstract

Peritoneal dialysis (PD) use increased in the United States with the introduction of a new Medicare prospective payment system in January 2011 that likely reduced financial disincentives for facility use of this home therapy. The expansion of PD to a broader population and facilities having less PD experience may have implications for patient outcomes. We assessed the impact of PD expansion on PD discontinuation and patient mortality. A prospective cohort study was conducted of patients treated with PD at 90 days of ESKD. Patients were grouped by study start date relative to the Medicare payment reform: prereform (July 1, 2008 to December 31, 2009; n=10,585), interim (January 1, 2010 to December 31, 2010; n=7832), and reform period (January 1, 2011 to December 31, 2012; n=18,742). Patient characteristics and facility PD experience were compared at baseline (day 91 of ESKD). Patients were followed for 3 years for the major outcomes of PD discontinuation and mortality using Cox proportional hazards models. Patient characteristics, including age, sex, race, ethnicity, rurality, cause of ESKD, and comorbidity, were similar or showed small changes across the three study periods. There was an increasing tendency for patients on PD to be treated in facilities with less PD experience (from 34% during the prereform period being treated in facilities averaging <14 patients on PD per year to 44% in the reform period). Patients treated in facilities with less PD experience had a higher rate of PD discontinuation than patients treated in facilities with the most experience (hazard ratio [HR], 1.16; 95% confidence interval [95% CI], 1.10 to 1.23 for the first versus fifth quintile of PD experience). Nevertheless, the risk of PD discontinuation fell during the late interim period (HR, 0.88; 95% CI, 0.82 to 0.95) and most of the reform period (from HR, 0.85; 95% CI, 0.79 to 0.91 to HR, 0.94; 95% CI, 0.87 to 1.01). Mortality risk was stable across the three study periods. In the context of expanding PD use and declining facility PD experience, the risk of PD discontinuation fell, and there was no adverse effect on mortality. This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_09_12_CJN01610219.mp3. Copyright © 2019 by the American Society of Nephrology.

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