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Emrani Z, Amiresmaili M, Daroudi R, Najafi MT, Akbari Sari A. Payment systems for dialysis and their effects: a scoping review. BMC Health Serv Res 2023; 23:45. [PMID: 36650516 PMCID: PMC9847119 DOI: 10.1186/s12913-022-08974-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 12/15/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND End stage renal disease (ESRD) is a major health concern and a large drain on healthcare resources. A wide range of payment methods are used for management of ESRD. The main aim of this study is to identify current payment methods for dialysis and their effects. METHOD In this scoping review Pubmed, Scopus, and Google Scholar were searched from 2000 until 2021 using appropriate search strategies. Retrieved articles were screened according to predefined inclusion criteria. Data about the study characteristics and study results were extracted by a pre-structured data extraction form; and were analyzed by a thematic analysis approach. RESULTS Fifty-nine articles were included, the majority of them were published after 2011 (66%); all of them were from high and upper middle-income countries, especially USA (64% of papers). Fee for services, global budget, capitation (bundled) payments, and pay for performance (P4P) were the main reimbursement methods for dialysis centers; and FFS, salary, and capitation were the main methods to reimburse the nephrologists. Countries have usually used a combination of methods depending on their situations; and their methods have been further developed over time specially from the retrospective payment systems (RPS) towards the prospective payment systems (PPS) and pay for performance methods. The main effects of the RPS were undertreatment of unpaid and inexpensive services, and over treatment of payable services. The main effects of the PPS were cost saving, shifting the service cost outside the bundle, change in quality of care, risk of provider, and modality choice. CONCLUSION This study provides useful insights about the current payment systems for dialysis and the effects of each payment system; that might be helpful for improving the quality and efficiency of healthcare.
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Affiliation(s)
- Zahra Emrani
- grid.411705.60000 0001 0166 0922Department of Health Policy, Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Amiresmaili
- grid.412105.30000 0001 2092 9755Health in Disasters and Emergencies Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Rajabali Daroudi
- grid.411705.60000 0001 0166 0922Department of Health Policy, Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Taghi Najafi
- grid.411705.60000 0001 0166 0922Nephrology Research Center, Tehran University of Medical Sciences, Tehran, Iran ,Center of Excellence in Nephrology, Tehran, Iran
| | - Ali Akbari Sari
- grid.411705.60000 0001 0166 0922Department of Health Policy, Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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Pearson J, Jacobson C, Ugochukwu N, Asare E, Kan K, Pace N, Han J, Wan N, Schonberger R, Andreae M. Geospatial analysis of patients' social determinants of health for health systems science and disparity research. Int Anesthesiol Clin 2023; 61:49-62. [PMID: 36480649 PMCID: PMC10107426 DOI: 10.1097/aia.0000000000000389] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Social context matters for health, healthcare processes/quality and patient outcomes. The social status and circumstances we are born into, grow up in and live under, are called social determinants of health; they drive our health, and how we access and experience care; they are the fundamental causes of disease outcomes. Such circumstances are influenced heavily by our location through neighborhood context, which relates to support networks. Geography can influence proximity to resources and is an important dimension of social determinants of health, which also encompass race/ethnicity, language, health literacy, gender identity, social capital, wealth and income. Beginning with an explanation of social determinants, we explore the use of Geospatial Analysis methods and geocoding, including the importance of collaborating with geography experts, the pitfalls of geocoding, and how geographic analysis can help us to understand patient populations within the context of Social Determinants of Health. We then explain mechanisms and methods of geospatial analysis with two examples: (1) Bayesian hierarchical regression with crossed random effects and (2) discontinuity regression i.e., change point analysis. We leveraged the local University of Utah and Yale cohorts of the Multicenter Perioperative Outcomes Group (MPOG.org ), a perioperative electronic health registry; we enriched the Utah cohort with US-census tract level social determinants of health after geocoding patient addresses and extracting social determinants of health from the National Neighborhood Database (NaNDA). We explain how to investigate the impact of US-census tract level community deprivation indices and racial/ethnic composition on (1) individual clinicians’ administration of risk-adjusted perioperative antiemetic prophylaxis, (2) patients’ decisions to defer cataract surgery at the cusp of Medicare eligibility and finally (3) methods to further characterize patient populations at risk through publicly available datasets in the context of public transit access. Our examples are not rigorous analyses, and our preliminary inferences should not be taken at face value, but rather seen as illustration of geospatial analysis processes and methods. Our worked examples show the potential utility of geospatial analysis, and in particular the power of geocoding patient addresses to extract US-census level social determinants of health from publicly available databases to enrich electronic health registries for healthcare disparity research and targeted health system level countermeasures.
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Affiliation(s)
- John Pearson
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Cameron Jacobson
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
| | | | - Elliot Asare
- Section of Surgical Oncology, Division of General Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Kelvin Kan
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Nathan Pace
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jiuying Han
- Department of Geography, University of Utah, Salt Lake City, Utah
| | - Neng Wan
- Department of Geography, University of Utah, Salt Lake City, Utah
| | - Robert Schonberger
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
| | - Michael Andreae
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
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Trivedi NN, Varshneya K, Calcei JB, Lin K, Sochaki KR, Voos JE, Safran MR, Calcei JG. Achilles Tendon Repairs: Identification of Risk Factors for and Economic Impact of Complications and Reoperation. Sports Health 2022; 15:124-130. [PMID: 35635017 PMCID: PMC9808838 DOI: 10.1177/19417381221087246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Compared with nonoperative management, Achilles tendon repair is associated with increased rates of complications and increased initial healthcare cost. However, data are currently lacking on the risk factors for these complications and the added healthcare cost associated with common preoperative comorbidities. HYPOTHESIS Identify the independent risk factors for complications and reoperation after acute Achilles tendon repair and calculate the added cost of care associated with having each preoperative risk factor. STUDY DESIGN Retrospective cohort study. LEVEL OF EVIDENCE Level 3. METHODS A retrospective review of a large commercial claims database was performed to identify patients who underwent primary operative management for Achilles tendon rupture between 2007 and 2016. The primary outcome measures of the study were risk factors for (1) postoperative complications, (2) revision surgery, and (3) increased healthcare resource utilization. RESULTS A total of 50,279 patients were included. The overall complication rate was 2.7%. The most common 30-day complication was venous thromboembolism (1.2%). The rate of revision surgery was 2.5% at 30 days and 4.3% at 2 years. Independent risk factors for 30-day complications in our cohort included increasing age, hyperlipidemia, hypertension, female sex, obesity, and diabetes. Independent risk factors for revision surgery within 2 years included female sex, tobacco use, hypertension, obesity, and the presence of any postoperative complication. The average 5-year cost of operative intervention was $17,307. The need for revision surgery had the largest effect on 5-year overall cost, increasing it by $6776.40. This was followed by the presence of a postoperative complication ($3780), female sex ($3207.70), and diabetes ($3105). CONCLUSION Achilles tendon repair is a relatively low-risk operation. Factors associated with postoperative complications include increasing age, hyperlipidemia, hypertension, female sex, obesity, and diabetes. Factors associated with the need for revision surgery include female sex, hypertension, obesity, and the presence of any postoperative complication. Female sex, diabetes, the presence of any complication, and the need for revision surgery had the largest added costs associated with them. CLINICAL RELEVANCE Surgeons can use this information for preoperative decision-making and during the informed consent process.
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Affiliation(s)
| | | | | | | | | | | | | | - Jacob G. Calcei
- Jacob G. Calcei, MD,
Assistant Professor, Department of Orthopaedic Surgery, University Hospitals,
Cleveland Medical Center, Case Western Reserve University School of Medicine,
Cleveland, OH 44106 ()
(Twitter: @drcalcei)
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Do current comorbidity indices accurately predict adverse events after operative fixation of hip fractures? A retrospective database review. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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5
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Weiner DE. Assessing quality care in kidney disease: The double‐edged sword versus the Gordian knot. Semin Dial 2020; 33:10-17. [DOI: 10.1111/sdi.12851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Lin E, Bhattacharya J, Chertow GM. Prior Hospitalization Burden and the Relatedness of 30-Day Readmissions in Patients Receiving Hemodialysis. J Am Soc Nephrol 2019; 30:323-335. [PMID: 30606782 DOI: 10.1681/asn.2018080858] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 11/15/2018] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Thirty-day readmissions are common in patients receiving hemodialysis and costly to Medicare. Because patients on hemodialysis have a high background hospitalization rate, 30-day readmissions might be less likely related to the index hospitalization than in patients with other conditions. METHODS In adults with Medicare receiving hemodialysis in the United States, we used multinomial logistic regression to evaluate whether prior hospitalization burden was associated with increased 30-day readmissions unrelated to index hospitalizations with a discharge date from January 1, 2013 to December 31, 2014. We categorized a hospitalization, 30-day readmission pair as "related" if the principal diagnoses came from the same organ system. RESULTS The adjusted probability of unrelated 30-day readmission after any index hospitalization was 19.1% (95% confidence interval [95% CI] 18.9% to 19.3%), 22.6% (95% CI, 22.4% to 22.8%), and 31.2% (95% CI, 30.8% to 31.5%) in patients with 0-1, 2-4, and ≥5 hospitalizations, respectively. Cardiovascular index hospitalizations had the highest adjusted probability of related 30-day readmission: 10.4% (95% CI, 10.2% to 10.7%), 13.6% (95% CI, 13.4% to 13.9%), and 20.8% (95% CI, 20.2% to 21.4%), respectively. Renal index hospitalizations had the lowest adjusted probability of related 30-day readmission: 2.0% (95% CI, 1.8% to 2.3%), 3.9% (95% CI, 3.4% to 4.4%), and 5.1% (95% CI, 4.3% to 5.9%), respectively. CONCLUSIONS High prior hospitalization burden increases the likelihood that patients receiving hemodialysis experience a 30-day readmission unrelated to the index hospitalization. Health care payers such as Medicare should consider incorporating clinical relatedness into 30-day readmission quality measures.
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Affiliation(s)
- Eugene Lin
- Division of Nephrology, Department of Medicine and .,Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California.,Kidney Research Center, University of Southern California/University Kidney Research Organization, Los Angeles, California.,Division of Nephrology, Department of Medicine and
| | - Jay Bhattacharya
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University, Stanford, California; and
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine and.,Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University, Stanford, California; and.,Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
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Kim CY, Sivasundaram L, LaBelle MW, Trivedi NN, Liu RW, Gillespie RJ. Predicting adverse events, length of stay, and discharge disposition following shoulder arthroplasty: a comparison of the Elixhauser Comorbidity Measure and Charlson Comorbidity Index. J Shoulder Elbow Surg 2018; 27:1748-1755. [PMID: 29798824 DOI: 10.1016/j.jse.2018.03.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 03/06/2018] [Accepted: 03/11/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Rising health care expenditures and the adoption of bundled-care initiatives require efficient resource allocation for shoulder arthroplasty. To determine a reliable and accessible metric for implementing perioperative care pathways, we compared the accuracy of the Elixhauser Comorbidity Measure (ECM) and Charlson Comorbidity Index (CCI) for predicting adverse events and postoperative discharge destination after shoulder arthroplasty. MATERIALS AND METHODS The National Inpatient Sample was queried for patients who underwent total shoulder arthroplasty or reverse total shoulder arthroplasty between 2002 and 2014. Logistic regression models were constructed with basic demographic variables and either the ECM or the CCI to predict inpatient deaths, complications, extended length of stay, and discharge disposition. The predictive discrimination of each model was evaluated using the concordance statistic (C-statistic). RESULTS We identified a total of 90,491 patients. The model incorporating both basic demographic variables and the complete set of ECM comorbidity variables provided the best predictive model, with a C-statistic of 0.867 for death, 0.752 for extended length of stay, and 0.81 for nonroutine discharge. The model's discrimination for postoperative complications was good, with C-statistics ranging from 0.641 to 0.879. CONCLUSION A predictive model using the ECM outperforms models using the CCI for anticipating resource utilization following shoulder arthroplasty. Our results may assist value-based reimbursement methods to promote quality of care and reduce health care expenditures.
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Affiliation(s)
- Chang-Yeon Kim
- Department of Orthopaedics, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Lakshmanan Sivasundaram
- Department of Orthopaedics, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Mark W LaBelle
- Department of Orthopaedics, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Nikunj N Trivedi
- Department of Orthopaedics, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Raymond W Liu
- Department of Orthopaedics, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Robert J Gillespie
- Department of Orthopaedics, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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Butler CR, Mehrotra R, Tonelli MR, Lam DY. The Evolving Ethics of Dialysis in the United States: A Principlist Bioethics Approach. Clin J Am Soc Nephrol 2016; 11:704-9. [PMID: 26912540 DOI: 10.2215/cjn.04780515] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Throughout the history of dialysis, four bioethical principles - beneficence, nonmaleficence, autonomy and justice - have been weighted differently based upon changing forces of technologic innovation, resource limitation, and societal values. In the 1960s, a committee of lay people in Seattle attempted to fairly distribute a limited number of maintenance hemodialysis stations guided by considerations of justice. As technology advanced and dialysis was funded under an amendment to the Social Security Act in 1972, focus shifted to providing dialysis for all in need while balancing the burdens of treatment and quality of life, supported by the concepts of beneficence and nonmaleficence. At the end of the last century, the importance of patient preferences and personal values became paramount in medical decisions, reflecting a focus on the principle of autonomy. More recently, greater recognition that health care financial resources are limited makes fair allocation more pressing, again highlighting the importance of distributive justice. The varying application and prioritization of these four principles to both policy and clinical decisions in the United States over the last 50 years makes the history of hemodialysis an instructive platform for understanding principlist bioethics. As medical technology evolves in a landscape of changing personal and societal values, a comprehensive understanding of an ethical framework for evaluating appropriate use of medical interventions enables the clinician to systematically negotiate and optimize difficult ethical situations.
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Affiliation(s)
| | - Rajnish Mehrotra
- Kidney Research Institute and Harborview Medical Center, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington; and
| | - Mark R Tonelli
- Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle, Washington
| | - Daniel Y Lam
- Division of Nephrology, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
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Thorsteinsdottir B, Swetz KM, Albright RC. The Ethics of Chronic Dialysis for the Older Patient: Time to Reevaluate the Norms. Clin J Am Soc Nephrol 2015; 10:2094-9. [PMID: 25873266 DOI: 10.2215/cjn.09761014] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Recent research highlights the potential burdens of hemodialysis for older patients with significant comorbidities, for whom there is clinical equipoise regarding the net benefits. With the advent of accountable care and bundled payment, previous incentives to offer hemodialysis to as many patients as possible are being replaced with a disincentive to dialyze high-risk patients. While this may offset the harm of overtreatment for some elderly patients, some voice concerns that the pendulum will swing too far back, with a return to ageist rationing of hemodialysis. Nephrologists should ensure that the patient's rights to be informed about the potential benefits and burdens of hemodialysis are respected, particularly because age, functional status, nutritional status, and comorbidities affect the net balance between benefits and burdens. Nephrologists are also called on to help patients make a decision, for which the patient's goals of care guide determination of potential benefit from hemodialysis. This article addresses concerns about present overtreatment and future risk of undertreatment of older adults with ESRD. It also discusses ways in which providers can ethically approach the question of initiation of hemodialysis in the elderly patient by including patient-specific estimates of prognosis, shared decision-making, and the use of specialist palliative care clinicians or ethics consultants for complex cases.
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Affiliation(s)
- Bjorg Thorsteinsdottir
- Department of Medicine, Division of Primary Care Internal Medicine, Biomedical Ethics Program, and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Keith M Swetz
- Division of General Internal Medicine, Biomedical Ethics Program, and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
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Zhang Y, Thamer M, Kshirsagar O, Cotter DJ, Schlesinger MJ. Dialysis chains and placement on the waiting list for a cadaveric kidney transplant. Transplantation 2014; 98:543-51. [PMID: 24798304 DOI: 10.1097/tp.0000000000000106] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The proliferation of multi-unit for-profit dialysis chains in the ESRD industry has raised concerns for patient quality of care including access to renal transplantation therapy (RTT). The effect of dialysis facility chain status on RTT is unknown. METHODS Data from the United States Renal Data System were used to identify 4,465 dialysis facilities and 56,714 dialysis patients who started hemodialysis in 2006. Patients were followed from initiation of hemodialysis in 2006 to placement on the renal transplant waiting list or to December 31, 2009. The role of dialysis facility chain status (affiliation, size, and ownership) on placement on the renal transplant waiting list was evaluated by multi-level mixed-effect regression models that account for clustering within facilities. RESULTS Patients from for-profit chain facilities, compared to nonprofit chain facilities, were 13% (95% CI 0.77-0.98) less likely to be waitlisted. In contrast, among nonchains, facility ownership did not influence likelihood of being waitlisted. There was also a marginally significant difference in waiting list placement by chain size: large chains compared with mid or small chains were 8% (95% CI 0.84-1.00) less likely to place patients on the waiting list. After adjustment for patient and facility characteristics, dialysis facility chain affiliation (chain-affiliated or not) was not found to be independently associated with the likelihood of placement on the transplant waitlist. CONCLUSION Dialysis chain affiliation expands previously observed ownership-related differences in placement on the waiting list. For-profit ownership of dialysis chain facilities appears to be a significant impediment to access to renal transplants.
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Affiliation(s)
- Yi Zhang
- 1 Medical Technology and Practice Patterns Institute, Bethesda, MD. 2 Yale School of Public Health, New Haven, CT. 3 Address correspondence to: Dennis Cotter, M.S.E., Medical Technology and Practice Patterns Institute, 5272 River Road, Suite 500, Bethesda, MD
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Proximity Does Not Equal Access: Racial Disparities in Access to High Quality Dialysis Facilities. J Racial Ethn Health Disparities 2014; 1:291-299. [PMID: 25419509 DOI: 10.1007/s40615-014-0036-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND For patients receiving hemodialysis, distance to their dialysis facility may be particularly important due to the need for thrice weekly dialysis. We sought to determine whether African-Americans and Whites differ in proximity and access to high quality dialysis facilities. METHODS We analyzed urban, Whites and African-Americans aged 18-65 receiving in-center hemodialysis linked to data on neighborhood and dialysis facility quality measures. In multivariable analyses, we examined the association between individual and neighborhood characteristics, and our outcomes: distance from home zip code to nearest dialysis facility, their current facility and the nearest high quality facility, as well as likelihood of receiving dialysis in a high quality facility. RESULTS African-Americans lived a half mile closer to a dialysis facility (B=-0.52) but traveled the same distance to their own dialysis facility compared to Whites. In initial analysis, African-Americans are 14% less likely than their White counterparts to attend a high quality dialysis facility (OR 0.86); and those disparities persist, though are reduced, even after adjusting for region, neighborhood poverty and percent African-American. In predominately African-American neighborhoods, individuals lived closer to high quality facilities (B=--5.92), but were 53% less likely to receive dialysis there (OR 0.47, highest group versus lowest, p<0.05). Living in a predominately African-American neighborhood explains 24% of racial disparity in attending a high quality facility. CONCLUSIONS African-Americans' proximity to high quality facilities does not lead to receiving care there. Institutional and social barriers may also play an important role in where people receive dialysis.
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Affiliation(s)
- Raymond Vanholder
- Renal Division, Section of Internal Medicine, Ghent University Hospital, B9000 Ghent, Belgium.
| | - Wim Van Biesen
- Renal Division, Section of Internal Medicine, Ghent University Hospital, B9000 Ghent, Belgium
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Thorsteinsdottir B, Swetz KM, Tilburt JC. Dialysis in the frail elderly--a current ethical problem, an impending ethical crisis. J Gen Intern Med 2013; 28:1511-6. [PMID: 23686511 PMCID: PMC3797329 DOI: 10.1007/s11606-013-2494-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 02/21/2013] [Accepted: 05/01/2013] [Indexed: 11/24/2022]
Abstract
The current practice of hemodialysis for the frail elderly frequently ignores core bioethical principles. Lack of transparency and shared decision making coupled with financial incentives to treat have resulted in problems of overtreatment near the end of life. Imminent changes in reimbursement for hemodialysis will reverse the financial incentives to favor not treating high-risk patients. In this article, we describe what is empirically known about the approach to hemodialysis today, and how it violates four core ethical principles. We then discuss how the new financial system turns physician and organizational incentives upside down in ways that may exacerbate the ethical dilemmas, but in the opposite direction.
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Whitman CB, Shreay S, Gitlin M, van Oijen MGH, Spiegel BMR. Clinical factors and the decision to transfuse chronic dialysis patients. Clin J Am Soc Nephrol 2013; 8:1942-51. [PMID: 23929931 PMCID: PMC3817895 DOI: 10.2215/cjn.00160113] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 06/11/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Red blood cell transfusion was previously the principle therapy for anemia in CKD but became less prevalent after the introduction of erythropoiesis-stimulating agents. This study used adaptive choice-based conjoint analysis to identify preferences and predictors of transfusion decision-making in CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A computerized adaptive choice-based conjoint survey was administered between June and August of 2012 to nephrologists, internists, and hospitalists listed in the American Medical Association Masterfile. The survey quantified the relative importance of 10 patient attributes, including hemoglobin levels, age, occult blood in stool, severity of illness, eligibility for transplant, iron indices, erythropoiesis-stimulating agents, cardiovascular disease, and functional status. Triggers of transfusions in common dialysis scenarios were studied, and based on adaptive choice-based conjoint-derived preferences, relative importance by performing multivariable regression to identify predictors of transfusion preferences was assessed. RESULTS A total of 350 providers completed the survey (n=305 nephrologists; mean age=46 years; 21% women). Of 10 attributes assessed, absolute hemoglobin level was the most important driver of transfusions, accounting for 29% of decision-making, followed by functional status (16%) and cardiovascular comorbidities (12%); 92% of providers transfused when hemoglobin was 7.5 g/dl, independent of other factors. In multivariable regression, Veterans Administration providers were more likely to transfuse at 8.0 g/dl (odds ratio, 5.9; 95% confidence interval, 1.9 to 18.4). Although transplant eligibility explained only 5% of decision-making, nephrologists were five times more likely to value it as important compared with non-nephrologists (odds ratio, 5.2; 95% confidence interval, 2.4 to 11.1). CONCLUSIONS Adaptive choice-based conjoint analysis was useful in predicting influences on transfusion decisions. Hemoglobin level, functional status, and cardiovascular comorbidities most strongly influenced transfusion decision-making, but preference variations were observed among subgroups.
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Affiliation(s)
- Cynthia B Whitman
- Departments of Research and, ¶Internal Medicine, Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, California;, †University of California at Los Angeles, Veterans Administration Center for Outcomes Research and Education, Los Angeles, California;, ‡Global Health Economics, Amgen, Inc., Thousand Oaks, California;, §Department of Internal Medicine, David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, California, ‖Department of Health Services, University of California at Los Angeles School of Public Health, Los Angeles, California
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Watnick S, Weiner DE, Shaffer R, Inrig J, Moe S, Mehrotra R. Comparing mandated health care reforms: the Affordable Care Act, accountable care organizations, and the Medicare ESRD program. Clin J Am Soc Nephrol 2012; 7:1535-43. [PMID: 22626961 DOI: 10.2215/cjn.01220212] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In addition to extending health insurance coverage, the Affordable Care Act of 2010 aims to improve quality of care and contain costs. To this end, the act allowed introduction of bundled payments for a range of services, proposed the creation of accountable care organizations (ACOs), and established the Centers for Medicare and Medicaid Innovation to test new care delivery and payment models. The ACO program began April 1, 2012, along with demonstration projects for bundled payments for episodes of care in Medicaid. Yet even before many components of the Affordable Care Act are fully in place, the Medicare ESRD Program has instituted legislatively mandated changes for dialysis services that resemble many of these care delivery reform proposals. The ESRD program now operates under a fully bundled, case-mix adjusted prospective payment system and has implemented Medicare's first-ever mandatory pay-for-performance program: the ESRD Quality Incentive Program. As ACOs are developed, they may benefit from the nephrology community's experience with these relatively novel models of health care payment and delivery reform. Nephrologists are in a position to assure that the ACO development will benefit from the ESRD experience. This article reviews the new ESRD payment system and the Quality Incentive Program, comparing and contrasting them with ACOs. Better understanding of similarities and differences between the ESRD program and the ACO program will allow the nephrology community to have a more influential voice in shaping the future of health care delivery in the United States.
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Spiegel BMR. Treatment center characteristics associated with better outcomes: a role for the medical director? Semin Dial 2012; 25:296-8. [PMID: 22607212 DOI: 10.1111/j.1525-139x.2012.01077.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Brennan M R Spiegel
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
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Tangri N, Tighiouart H, Meyer KB, Miskulin DC. Both patient and facility contribute to achieving the Centers for Medicare and Medicaid Services' pay-for-performance target for dialysis adequacy. J Am Soc Nephrol 2011; 22:2296-302. [PMID: 22025629 DOI: 10.1681/asn.2010111137] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The Centers for Medicare and Medicaid Services (CMS) designated the achieved urea reduction ratio (URR) as a pay-for-performance measure, but to what extent this measure reflects patient characteristics and adherence instead of its intent to reflect facility performance is unknown. Here, we quantified the contributions of patient case-mix and adherence to the variability in achieving URR targets across dialysis facilities. We found that 92% of 10,069 hemodialysis patients treated at 173 facilities during the last quarter of 2004 achieved the target URR ≥65%. Mixed-effect models with random intercept for dialysis facility revealed a significant facility effect: 11.5% of the variation in achievement of target URR was attributable to the facility level. Adjusting for patient case-mix reduced the proportion of variation attributable to the facility level to 6.7%. Patient gender, body surface area, dialysis access, and adherence with treatment strongly associated with achievement of the URR target. We could not identify specific facility characteristics that explained the remaining variation between facilities. These data suggest that if adherence is not a modifiable patient characteristic, providers could be unfairly penalized for caring for these patients under current CMS policy. These penalties may have unintended consequences.
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Affiliation(s)
- Navdeep Tangri
- Department of Medicine, Division of Nephrology, Seven Oaks General Hospital, University of Manitoba, 2PD-13 2300 McPhillips Street, Winnipeg MB, R2V3M3 Canada.
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Menzin J, Lines LM, Weiner DE, Neumann PJ, Nichols C, Rodriguez L, Agodoa I, Mayne T. A review of the costs and cost effectiveness of interventions in chronic kidney disease: implications for policy. PHARMACOECONOMICS 2011; 29:839-861. [PMID: 21671688 DOI: 10.2165/11588390-000000000-00000] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Given rising healthcare costs and a growing population of patients with chronic kidney disease (CKD), there is an urgent need to identify health interventions that provide good value for money. For this review, the English-language literature was searched for studies of interventions in CKD reporting an original incremental cost-utility (cost per QALY) or cost-effectiveness (cost per life-year) ratio. Published cost studies that did not report cost-effectiveness or cost-utility ratios were also reviewed. League tables were then created for both cost-utility and cost-effectiveness ratios to assess interventions in patients with stage 1-4 CKD, waitlist and transplant patients and those with end-stage renal disease (ESRD). In addition, the percentage of cost-saving or dominant interventions (those that save money and improve health) was compared across these three disease categories. A total of 84 studies were included, contributing 72 cost-utility ratios, 20 cost-effectiveness ratios and 42 other cost measures. Many of the interventions were dominant over the comparator, indicating better health outcomes and lower costs. For the three disease categories, the greatest number of dominant or cost-saving interventions was reported for stage 1-4 CKD patients, followed by waitlist and transplant recipients and those with ESRD (91%, 87% and 55% of studies reporting a dominant or cost-saving intervention, respectively). There is evidence of opportunities to lower costs in the treatment of patients with CKD, while either improving or maintaining the quality of care. In order to realize these cost savings, efforts will be required to promote and effectively implement changes in treatment practices.
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Clint Parker J. Cherry Picking in ESRD: An Ethical Challenge in the Era of Pay for Performance. Semin Dial 2011; 24:5-8. [DOI: 10.1111/j.1525-139x.2010.00806.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Spiegel BM, Farid M, Esrailian E, Talley J, Chang L. Is irritable bowel syndrome a diagnosis of exclusion?: a survey of primary care providers, gastroenterologists, and IBS experts. Am J Gastroenterol 2010; 105:848-58. [PMID: 20197761 PMCID: PMC2887205 DOI: 10.1038/ajg.2010.47] [Citation(s) in RCA: 119] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Guidelines emphasize that irritable bowel syndrome (IBS) is not a diagnosis of exclusion and encourage clinicians to make a positive diagnosis using the Rome criteria alone. Yet many clinicians are concerned about overlooking alternative diagnoses. We measured beliefs about whether IBS is a diagnosis of exclusion, and measured testing proclivity between IBS experts and community providers. METHODS We developed a survey to measure decision-making in two standardized patients with Rome III-positive IBS, including IBS with diarrhea (D-IBS) and IBS with constipation (C-IBS). The survey elicited provider knowledge and beliefs about IBS, including testing proclivity and beliefs regarding IBS as a diagnosis of exclusion. We surveyed nurse practitioners, primary care physicians, community gastroenterologists, and IBS experts. RESULTS Experts were less likely than nonexperts to endorse IBS as a diagnosis of exclusion (8 vs. 72%; P<0.0001). In the D-IBS vignette, experts were more likely to make a positive diagnosis of IBS (67 vs. 38%; P<0.001), to perform fewer tests (2.0 vs. 4.1; P<0.01), and to expend less money on testing (US$297 vs. $658; P<0.01). Providers who believed IBS is a diagnosis of exclusion ordered 1.6 more tests and consumed $364 more than others (P<0.0001). Experts only rated celiac sprue screening and complete blood count as appropriate in D-IBS; nonexperts rated most tests as appropriate. Parallel results were found in the C-IBS vignette. CONCLUSIONS Most community providers believe IBS is a diagnosis of exclusion; this belief is associated with increased resource use. Experts comply more closely with guidelines to diagnose IBS with minimal testing. This disconnect suggests that better implementation of guidelines is warranted to minimize variation and improve cost-effectiveness of care.
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Affiliation(s)
- Brennan M.R. Spiegel
- Department of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA, Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA, Department of Health Services, UCLA School of Public Health, Los Angeles, California, USA, CURE Digestive Diseases Research Center, Los Angeles, California, USA, Center for Neurobiology of Stress, David Geffen School of Medicine at UCLA, Los Angeles, California, USA, UCLA/VA Center for Outcomes Research and Education, Los Angeles, California, USA
| | - Mary Farid
- Department of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA, Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Eric Esrailian
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA, UCLA/VA Center for Outcomes Research and Education, Los Angeles, California, USA
| | - Jennifer Talley
- Department of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA, Center for Neurobiology of Stress, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Lin Chang
- Department of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA, Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA, Center for Neurobiology of Stress, David Geffen School of Medicine at UCLA, Los Angeles, California, USA, UCLA/VA Center for Outcomes Research and Education, Los Angeles, California, USA
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Mendelssohn DC, Wish JB. Dialysis delivery in Canada and the United States: a view from the trenches. Am J Kidney Dis 2009; 54:954-64. [PMID: 19726118 DOI: 10.1053/j.ajkd.2009.05.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Accepted: 05/12/2009] [Indexed: 11/11/2022]
Abstract
Although the general framework for health care delivery is vastly different in Canada and the United States, the framework for dialysis delivery is less divergent. However, the 2 systems have evolved very differently. Examined during the past 20 years, it is apparent that the dialysis system in the United States has undergone profound change, whereas the system in Canada is relatively stagnant. Most of the change in the United States has been positive, and this evolutionary change is expected to continue. In Canada, a system that historically has worked reasonably well is now showing severe signs of suboptimal performance that would be expected to get worse if no effort is made to improve it. This article, written from the perspective of 2 academic clinicians, tries to describe similarities and differences, identify strengths and weaknesses, and serve as a catalyst for discussions about improving both systems. Just as no dialysis treatment modality is perfect, the same can be said for dialysis delivery systems. Empirical methods to objectively evaluate the impact of change must be included in the design and implementation of new initiatives in the United States and Canada.
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