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Cron DC, Tsai TC, Patzer RE, Husain SA, Xiang L, Adler JT. The Association of Dialysis Facility Payer Mix With Access to Kidney Transplantation. JAMA Netw Open 2023; 6:e2322803. [PMID: 37432684 PMCID: PMC10336615 DOI: 10.1001/jamanetworkopen.2023.22803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/25/2023] [Indexed: 07/12/2023] Open
Abstract
Importance Insurance coverage for patients with end-stage kidney disease has shifted toward more commercially insured patients at dialysis facilities. The associations among insurance status, facility-level payer mix, and access to kidney transplantation are unclear. Objective To determine the association of dialysis facility commercial payer mix and 1-year incidence of wait-listing for kidney transplantation, and to delineate the association of commercial insurance at the patient vs facility level. Design, Setting, and Participants This retrospective population-based cohort study used data from the United States Renal Data System from 2013 to 2018. Participants included patients aged 18 to 75 years initiating chronic dialysis between 2013 and 2017, excluding patients with a prior kidney transplant or with major contraindications to kidney transplant. Data were analyzed from August 2021 and May 2023. Exposure Dialysis facility commercial payer mix, calculated as the proportion of patients with commercial insurance per facility. Main Outcomes and Measures The primary outcome was patients added to a waiting list for kidney transplant within 1 year of dialysis initiation. Multivariable Cox regression, censoring for death, was used to adjust for patient-level (demographic, socioeconomic, and medical) and facility-level factors. Results A total of 233 003 patients (97 617 [41.9%] female patients; mean [SD] age, 58.0 [12.1] years) across 6565 facilities met inclusion criteria. Participants included 70 062 Black patients (30.1%), 42 820 Hispanic patients (18.4%), 105 368 White patients (45.2%), and 14 753 patients (6.3%) who identified as another race or ethnicity (eg, American Indian or Alaskan Native, Asian, Native Hawaiian or Pacific Islander, and multiracial). Of 6565 dialysis facilities, the mean (SD) commercial payer mix was 21.2% (15.6 percentage points). Patient-level commercial insurance was associated with increased incidence of wait-listing (adjusted hazard ratio [aHR], 1.86; 95% CI, 1.80-1.93; P < .001). At the facility-level and before covariate adjustment, higher commercial payer mix was associated with increased wait-listing (fourth vs first payer mix quartile [Q]: HR, 1.79; 95% CI, 1.67-1.91; P < .001). However, after covariate-adjustment, including adjusting for patient-level insurance status, commercial payer mix was not significantly associated with outcome (Q4 vs Q1: aHR, 1.02; 95% CI, 0.95-1.09; P = .60). Conclusions and Relevance In this national cohort study of patients newly initiated on chronic dialysis, although patient-level commercial insurance was associated with higher access to the kidney transplant waiting lists, there was no independent association of facility-level commercial payer mix with patients being added to waiting lists for transplant. As the landscape of insurance coverage for dialysis evolves, the potential downstream impact on access to kidney transplant should be monitored.
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Affiliation(s)
- David C. Cron
- Department of Surgery, Massachusetts General Hospital, Boston
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Thomas C. Tsai
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Rachel E. Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Medicine, Emory Medical School, Atlanta, Georgia
| | - Syed A. Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
- The Columbia University Renal Epidemiology Group, New York, New York
| | - Lingwei Xiang
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Joel T. Adler
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Transplantation, Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin
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3
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Mark PB, Carrero JJ, Matsushita K, Sang Y, Ballew SH, Grams ME, Coresh J, Surapaneni A, Brunskill NJ, Chalmers J, Chan L, Chang AR, Chinnadurai R, Chodick G, Cirillo M, de Zeeuw D, Evans M, Garg AX, Gutierrez OM, Heerspink HJL, Heine GH, Herrington WG, Ishigami J, Kronenberg F, Lee JY, Levin A, Major RW, Marks A, Nadkarni GN, Naimark DMJ, Nowak C, Rahman M, Sabanayagam C, Sarnak M, Sawhney S, Schneider MP, Shalev V, Shin JI, Siddiqui MK, Stempniewicz N, Sumida K, Valdivielso JM, van den Brand J, Yee-Moon Wang A, Wheeler DC, Zhang L, Visseren FLJ, Stengel B. Major cardiovascular events and subsequent risk of kidney failure with replacement therapy: a CKD Prognosis Consortium study. Eur Heart J 2023; 44:1157-1166. [PMID: 36691956 PMCID: PMC10319959 DOI: 10.1093/eurheartj/ehac825] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 12/14/2022] [Accepted: 12/23/2022] [Indexed: 01/25/2023] Open
Abstract
AIMS Chronic kidney disease (CKD) increases risk of cardiovascular disease (CVD). Less is known about how CVD associates with future risk of kidney failure with replacement therapy (KFRT). METHODS AND RESULTS The study included 25 903 761 individuals from the CKD Prognosis Consortium with known baseline estimated glomerular filtration rate (eGFR) and evaluated the impact of prevalent and incident coronary heart disease (CHD), stroke, heart failure (HF), and atrial fibrillation (AF) events as time-varying exposures on KFRT outcomes. Mean age was 53 (standard deviation 17) years and mean eGFR was 89 mL/min/1.73 m2, 15% had diabetes and 8.4% had urinary albumin-to-creatinine ratio (ACR) available (median 13 mg/g); 9.5% had prevalent CHD, 3.2% prior stroke, 3.3% HF, and 4.4% prior AF. During follow-up, there were 269 142 CHD, 311 021 stroke, 712 556 HF, and 605 596 AF incident events and 101 044 (0.4%) patients experienced KFRT. Both prevalent and incident CVD were associated with subsequent KFRT with adjusted hazard ratios (HRs) of 3.1 [95% confidence interval (CI): 2.9-3.3], 2.0 (1.9-2.1), 4.5 (4.2-4.9), 2.8 (2.7-3.1) after incident CHD, stroke, HF and AF, respectively. HRs were highest in first 3 months post-CVD incidence declining to baseline after 3 years. Incident HF hospitalizations showed the strongest association with KFRT [HR 46 (95% CI: 43-50) within 3 months] after adjustment for other CVD subtype incidence. CONCLUSION Incident CVD events strongly and independently associate with future KFRT risk, most notably after HF, then CHD, stroke, and AF. Optimal strategies for addressing the dramatic risk of KFRT following CVD events are needed.
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Affiliation(s)
- Patrick B Mark
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | - Juan J Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Huddinge, Sweden
- Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD 21205, USA
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD 21205, USA
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD 21205, USA
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD 21205, USA
- Department of Medicine, New York University Grossman School of Medicine, 227 East 30th Street, #825 New York, NY 10016, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD 21205, USA
| | - Aditya Surapaneni
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD 21205, USA
| | - Nigel J Brunskill
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Lili Chan
- Department of Medicine, Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alex R Chang
- Departments of Nephrology and Population Health Sciences, Geisinger Health, 100 N Academy Ave, Danville, PA 17822, USA
| | - Rajkumar Chinnadurai
- Department of Renal Medicine, Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - Gabriel Chodick
- Medical Division, Maccabi Healthcare Services, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Massimo Cirillo
- Dept. "Scuola Medica Salernitana" University of Salerno Fisciano (SA), Italy
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center, Hanzeplein 1, 9713 GZ, Groningen, Netherlands
| | - Marie Evans
- Department of Clinical Intervention, and Technology (CLINTEC), Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Amit X Garg
- ICES, London, Ontario, Canada
- Division of Nephrology, Western University, London, Ontario, Canada
| | - Orlando M Gutierrez
- Departments of Epidemiology and Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center, Hanzeplein 1, 9713 GZ, Groningen, Netherlands
| | - Gunnar H Heine
- Saarland University Medical Center, Internal Medicine IV, Nephrology and Hypertension, Medizinische Klinik IIWilhelm-Epstein-Straße 4 60431 Frankfurt am Main, Germany
| | - William G Herrington
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health (NDPH), and Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH, University of Oxford, Richard Doll Building Old Road Campus Oxford, Oxfordshire, OX3 7LF, United Kingdom
| | - Junichi Ishigami
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD 21205, USA
| | - Florian Kronenberg
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Jun Young Lee
- Transplantation Center, Department of Nephrology, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju 26426, Korea
| | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - Rupert W Major
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Angharad Marks
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Girish N Nadkarni
- Department of Medicine, Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David M J Naimark
- Sunnybrook Hospital, University of Toronto, Rm 3861929 Bayview Ave. Toronto, Ontario M4G 3E8, Canada
| | - Christoph Nowak
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Mahboob Rahman
- Division of Nephrology, Department of Medicine, Case Western Reserve University, Cleveland, OH
| | - Charumathi Sabanayagam
- Ocular Epidemiology Research Group, Singapore Eye Research Institute, Singapore National Eye Centre, The Academia, 20 College Road, Discovery Tower Level 6, Singapore (169856), Singapore
- Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road Level 11, Singapore (119228), Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program (EYE-ACP), Duke-NUS Medical School, 8 College Road, Singapore (169857), Singapore
| | - Mark Sarnak
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | | | - Markus P Schneider
- Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Varda Shalev
- Institute for Health and Research and Innovation, Maccabi Healthcare Services and Tel Aviv University, Tel Aviv, Israel
| | - Jung-Im Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD 21205, USA
| | - Moneeza K Siddiqui
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, United Kingdom
| | | | - Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - José M Valdivielso
- Vascular & Renal Translational Research Group, IRBLleida, Spain and Spanish Research Network for Renal Diseases (RedInRen. ISCIII), Lleida, Spain
| | - Jan van den Brand
- Department of Nephrology, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, 102 Pok Fu Lam Road, Pok Fu Lam, Hong Kong SAR, Hong Kong
| | - David C Wheeler
- Centre for Nephrology, University College London, London, United Kingdom
| | - Lihua Zhang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, P.R. China
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Benedicte Stengel
- Clinical Epidemiology team, Centre for Research in Epidemiology and Population Health (CESP), University Paris-Saclay, UVSQ, Inserm, Villejuif, France
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4
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League RJ, Eliason P, McDevitt RC, Roberts JW, Wong H. Assessment of Spending for Patients Initiating Dialysis Care. JAMA Netw Open 2022; 5:e2239131. [PMID: 36306129 PMCID: PMC9617169 DOI: 10.1001/jamanetworkopen.2022.39131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Despite a widespread belief that private insurers spend large amounts on health care for enrollees receiving dialysis, data limitations over the past decade have precluded a comprehensive analysis of the topic. OBJECTIVE To examine the amount and types of increases in health care spending for privately insured patients associated with initiating dialysis care. DESIGN, SETTING, AND PARTICIPANTS A cohort study covering calendar years 2012 to 2019 included patients with kidney failure who had employer-sponsored insurance for 12 months following dialysis initiation. Data analysis was performed from August 27, 2021, to August 18, 2022. The data cover the entirety of the US and were obtained from the Health Care Cost Institute. The data include all medical claims for enrollees in employer-sponsored health insurance plans offered by multiple major health care insurers within the US. Participants included patients younger than 65 years who were continuously enrolled in these plans in the 12 months before and after their first claim for dialysis care. Patients also had to have nonmissing documented key characteristics, such as sex, race and ethnicity, and health characteristics. EXPOSURES A claim for dialysis care. MAIN OUTCOMES AND MEASURES Out-of-pocket, inpatient, outpatient, physician services, prescription medication, and total health care spending. The hypothesis tested was formulated before data collection. RESULTS The sample included 309 800 enrollee-months, which was a balanced panel of 25 months for 12 392 enrollees. At baseline, 7534 patients (61%) were male, 5415 (44%) were aged 55 to 64 years, and patients had been enrolled with their insurer for a mean of 30 months (95% CI, 29.9-30.1 months). In the 12 months before initiating dialysis care, total monthly health care spending was $5025 per patient per month (95% CI, $4945-$5106). Dialysis care initiation was associated with an increase in total monthly spending of $14 685 (95% CI, $14 413-$14 957). This increase occurred across all spending categories (dialysis, nondialysis outpatient, inpatient, physician services, and prescription drugs). Monthly patient out-of-pocket spending increased by $170 (95% CI, $162-$178). These spending increases occurred abruptly, beginning about 2 months before dialysis initiation, and remained increased for the subsequent 12 months. CONCLUSIONS AND RELEVANCE In this cohort study, evidence that private insurers experience significant, sustained increases in spending when patients initiated dialysis was noted. The findings suggest that proposed policies aimed at limiting the amount dialysis facilities charge private insurers and the enrollees has the potential to reduce health care spending in this high-cost population.
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Affiliation(s)
- Riley J. League
- Department of Economics, Duke University, Durham, North Carolina
| | - Paul Eliason
- Department of Economics, Brigham Young University, Provo, Utah
| | - Ryan C. McDevitt
- Fuqua School of Business, Duke University, Durham, North Carolina
| | - James W. Roberts
- Department of Economics, Duke University, Durham, North Carolina
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Heather Wong
- Department of Economics, Duke University, Durham, North Carolina
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