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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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Stephens JM, Fox KM, Desai P, Cheng S, Goodman WG, Kendrick JB. Calcimimetic use in US hemodialysis facilities in first 2 years after the launch of etelcalcetide: A descriptive analysis of real-world clinical practice and outcomes. Hemodial Int 2021; 26:243-254. [PMID: 34931443 DOI: 10.1111/hdi.12996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION This study described control of parathyroid hormone (PTH), phosphorus, and corrected calcium in adults initiating calcimimetics in small dialysis organizations after the introduction of etelcalcetide. METHODS This retrospective study using Visonex Clarity electronic health records between October 1, 2017, and December 31, 2019, identified adults ≥ 18 years of age receiving in-center hemodialysis as either a cinacalcet or etelcalcetide initiator based on their first calcimimetic use in 2018 (index date) with no prior calcimimetic use in the 3 months preindex date. Patients were stratified by PTH at index date and were followed for 15 months. Subcohorts of patients who were persistent on a single calcimimetic for 15 months and of patients who had their calcimimetic changed from cinacalcet to etelcalcetide were also analyzed. FINDINGS A total of 677 patients initiated cinacalcet and 711 initiated etelcalcetide. Mean PTH (pg/ml), phosphorus, and corrected calcium (mg/dl) at baseline were 864, 5.9, and 9.3 for cinacalcet and 804, 5.9, and 9.4 for etelcalcetide, respectively. During follow-up, the proportion of initiators considered in-target (monthly average PTH < 600) increased from 48% to 62% with cinacalcet and from 56% to 86% with etelcalcetide in the baseline PTH 600 to < 800 subgroup; increased from 30% to 64% with cinacalcet and 31% to 59% with etelcalcetide among those with baseline PTH 800 to < 1000; and increased from 14% to 41% with cinacalcet and 12% to 58% with etelcalcetide among those with baseline PTH ≥1000. A similar pattern was observed for persistent users (n = 646). For patients changed from cinacalcet to etelcalcetide (n = 183), the proportion of patients considered in-target increased from 22% in the month prior to the treatment change to 51% in Month 6 postchange. DISCUSSION Patients initiating calcimimetics at lower baseline PTH had better biochemical control than patients starting at higher PTH. Patients changed from cinacalcet to etelcalcetide had improvements in PTH control postchange.
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Sloan CE, Hoffman A, Maciejewski ML, Coffman CJ, Trogdon JG, Wang V. Trends in Dialysis Industry Consolidation After Medicare Payment Reform, 2006-2016. JAMA HEALTH FORUM 2021; 2:e213626. [PMID: 35977264 PMCID: PMC8796909 DOI: 10.1001/jamahealthforum.2021.3626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 09/20/2021] [Indexed: 11/14/2022] Open
Abstract
Question Findings Meaning Importance Objective Design, Setting, and Participants Exposures Main Outcomes and Measures Results Conclusions and Relevance
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Affiliation(s)
- Caroline E. Sloan
- Department of Medicine, Duke University Health System, Durham, North Carolina
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, North Carolina
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Abby Hoffman
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matthew L. Maciejewski
- Department of Medicine, Duke University Health System, Durham, North Carolina
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Cynthia J. Coffman
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Justin G. Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Virginia Wang
- Department of Medicine, Duke University Health System, Durham, North Carolina
- Health Services Research and Development Center of Innovation, Durham VA Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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Roetker NS, Guo H, Decker-Palmer MR, Peng Y, Wetmore JB. Changes in hemodialysis catheter management after introduction of the end-stage renal disease prospective payment system. BMC Nephrol 2021; 22:8. [PMID: 33407237 PMCID: PMC7788942 DOI: 10.1186/s12882-020-02222-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/23/2020] [Indexed: 11/10/2022] Open
Abstract
Background We investigated whether implementation of the end-stage renal disease prospective payment system (ESRD PPS) was associated with changes in thrombolytic therapy use and other aspects of catheter management in hemodialysis (HD) patients. Methods Using quarterly, period prevalent cohorts of patients undergoing maintenance HD with a catheter in the US Renal Data System (2008–2015), we studied rates of claims for within- and outside-HD-unit thrombolytic use, and thrombus/fibrin sheath removal, and rates of delayed HD treatment after ESRD PPS implementation, January 1, 2011. Associations between PPS implementation and change in trend of rates of each outcome were assessed using covariate-adjusted Poisson regression, using a piecewise linear function for quarter-time (with breakpoint at PPS implementation). Results Among an average of 69,428 quarterly catheter users, rates of claims for within-HD-unit thrombolytic use declined from 236.6 (Q1–2008) to 81.4 (Q4–2012) per 100 person-years (P < 0.0001, PPS association with change in trend); rates of claims for thrombus/fibrin sheath removal procedures increased from 3.9 (Q1–2008) to 8.8 (Q3–2015) per 100 person-years (P = 0.0001, PPS association with change in trend). Rates of delayed HD treatment increased from 1.6 (Q2–2008) to 2.3 (Q3–2015) per patient-quarter, although PPS implementation was associated with a decrease in this rising trend (1.6% increase per quarter pre-PPS, 1.2% post-PPS; P < 0.0001, change in trend). Conclusions After PPS implementation, thrombolytic use decreased and thrombus/fibrin sheath removal increased. The increasing trend in delayed HD treatment appeared to slow after PPS implementation, but delayed sessions continued to increase year over year for unclear reasons. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-020-02222-9.
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Affiliation(s)
- Nicholas S Roetker
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, 701 Park Ave., Suite S2.100, Minneapolis, MN, 55415, USA.
| | - Haifeng Guo
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, 701 Park Ave., Suite S2.100, Minneapolis, MN, 55415, USA
| | | | - Yi Peng
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, 701 Park Ave., Suite S2.100, Minneapolis, MN, 55415, USA
| | - James B Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, 701 Park Ave., Suite S2.100, Minneapolis, MN, 55415, USA.,Division of Nephrology, Hennepin County Medical Center and Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Greene B, Kim SJ, McCarthy EP, Pasternak JD. Effects of Social Disparities on Management and Surgical Outcomes for Patients with Secondary Hyperparathyroidism. World J Surg 2020; 44:537-543. [PMID: 31570954 DOI: 10.1007/s00268-019-05207-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Nearly 80% of chronic renal failure patients have secondary hyperparathyroidism. Cinacalcet is used to lower parathyroid hormone; however, it is expensive and has side effects. When secondary hyperparathyroidism is resistant to medication or medications are inaccessible, parathyroidectomy is performed. Race and socioeconomic status influence access to care and surgical outcomes. We sought to evaluate the effect of race and socioeconomic status on parathyroidectomy rate as well as surgical outcomes of patients with secondary hyperparathyroidism. METHODS We undertook cross-sectional analysis of adults diagnosed with secondary hyperparathyroidism in the USA between 2012 and 2014, using the National Inpatient Sample. Univariate and multivariate analyses were used to determine associations between social disparities, likelihood to undergo parathyroidectomy, and surgical outcomes. RESULTS Between 2012 and 2014, a national estimate of 724,170 hospitalizations were identified where patients had a diagnosis of secondary hyperparathyroidism. Operative rate was 0.67%. By socioeconomic status, differences in rates of surgery in the poorest compared to the richest were not significant (0.74% vs. 0.55%, OR 1.08, p = 0.5). African-American patients had higher rates of parathyroidectomy compared to Caucasians (1 vs. 0.74%, OR 1.49, p < 0.001). African-American patients also had a trend toward more complications and greater length of stay. CONCLUSIONS According to a large administrative dataset, parathyroidectomy for secondary hyperparathyroidism is seldom used in the USA. African-American patients have higher rates of surgical management. Surgical outcomes may be affected by race. Clinicians treating secondary hyperparathyroidism should be aware of existing disparities within their health system.
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Affiliation(s)
- Brittany Greene
- Division of General Surgery, Department of Surgery, University Health Network, Toronto General Hospital, 10 En 214, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - S Joseph Kim
- Division of Nephrology, Department of Medicine, University Health Network, 585 University Avenue, 11-PMB-129, Toronto, ON, M5G 2N2, Canada
| | - Ellen P McCarthy
- Department of Epidemiology, Harvard School of Public Health, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Jesse D Pasternak
- Division of General Surgery, Department of Surgery, University Health Network, Toronto General Hospital, 10 En 214, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
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Hall R, Platt A, Wilson J, Ephraim PL, Hwang AS, Chen A, Weiner DE, Boulware LE, Pendergast J, Scialla JJ. Trends in Mineral Metabolism Treatment Strategies in Patients Receiving Hemodialysis in the United States. Clin J Am Soc Nephrol 2020; 15:1603-1613. [PMID: 33046525 PMCID: PMC7646241 DOI: 10.2215/cjn.04350420] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 09/01/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES With multiple medications indicated for mineral metabolism, dialysis providers can apply various strategies to achieve target phosphate and parathyroid hormone (PTH) levels. We describe common prescribing patterns and practice variation in mineral metabolism treatment strategies over the last decade. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In a cohort of adults initiating hemodialysis at Dialysis Clinic, Inc. facilities, we assessed prescriptions of vitamin D sterols, phosphate binders, and cinacalcet longitudinally. To identify the influence of secular trends in clinical practice, we stratified the cohort by dialysis initiation year (2006-2008, 2009-2011, and 2012-2015). To measure practice variation, we estimated the median odds ratio for prescribing different mineral metabolism treatment strategies at 12 months post-dialysis initiation across facilities using mixed effects multinomial logistic regression. Sensitivity analyses evaluated strategies used after detection of first elevated PTH. RESULTS Among 23,549 incident patients on hemodialysis, there was a decline in vitamin D sterol-based strategies and a corresponding increase in strategies without PTH-modifying agents (i.e., phosphate binders alone or no mineral metabolism medications) and cinacalcet-containing treatment strategies between 2006 and 2015. The proportion with active vitamin D sterol-based strategies at dialysis initiation decreased across cohorts: 15% (2006-2008) to 5% (2012-2015). The proportion with active vitamin D sterol-based strategies after 18 months of dialysis decreased across cohorts: 52% (2006-2008) to 34% (2012-2015). The odds of using individual strategies compared with reference (active vitamin D sterol with phosphate binder) varied from 1.5- to two-fold across facilities in 2006-2008 and 2009-2011 cohorts, and increased to two- to three-fold in the 2012-2015 cohort. Findings were similar in sensitivity analyses starting from first elevated PTH measurement. CONCLUSIONS Over time, mineral metabolism management involved less use of vitamin D sterol-based strategies, greater use of both more conservative and cinacalcet-containing strategies, and increased practice variation, suggesting growing equipoise.
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Affiliation(s)
- Rasheeda Hall
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Alyssa Platt
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Jonathan Wilson
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Patti L. Ephraim
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Angelina S. Hwang
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Angel Chen
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Daniel E. Weiner
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - L. Ebony Boulware
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Jane Pendergast
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Julia J. Scialla
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Departments of Medicine and Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia
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Norouzi S, Zhao B, Awan A, Winkelmayer WC, Ho V, Erickson KF. Bundled Payment Reform and Dialysis Facility Closures in ESKD. J Am Soc Nephrol 2020; 31:579-590. [PMID: 32019784 PMCID: PMC7062226 DOI: 10.1681/asn.2019060575] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 12/01/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND In 2011, inclusion of injectable medications into an expanded ESKD payment bundle prompted concerns that dialysis facilities facing higher costs might close, disrupting care delivery and access to care. Whether this policy change influenced dialysis facility closures is unknown. METHODS To examine whether facility closures increased after 2011 and whether factors influencing closures changed, we analyzed US Renal Data System registry data to identify all patients receiving in-center hemodialysis from 2006 through 2015 and to track dialysis facility closures. We used interrupted time series logistic regression models and estimated marginal effects to examine immediate and longer-term changes in the likelihood of being affected by facility closures following payment reform. We also examined whether associations between selected predictors of closures indicating populations at "high risk" of closure (patient characteristics, facility characteristics, and geography-related characteristics) and closures changed after payment reform. RESULTS Dialysis facility closures were uncommon over the study period. In adjusted models, the relative odds of experiencing a closure declined by 37% (odds ratio [OR], 0.63; 95% confidence interval [95% CI], 0.59 to 0.67) immediately after payment reform and declined by an additional 6% (OR, 0.94; 95% CI, 0.91 to 0.97) annually thereafter, corresponding to a 0.3% lower absolute probability of closure in 2015 in association with payment reform. Patients who were black and who dialyzed at small, hospital-based facilities experienced slight increases in closures following payment reform, whereas Hispanic and Medicare/Medicaid dual-eligible patients experienced slight decreases in closures. CONCLUSIONS Expansion of the ESKD payment bundle was not associated with increased closure of dialysis facilities, although the likelihood of closures changed slightly for some higher-risk populations.
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Affiliation(s)
| | | | | | | | - Vivian Ho
- Baker Institute for Public Policy, Rice University, Houston, Texas
| | - Kevin F Erickson
- Section of Nephrology and
- Baker Institute for Public Policy, Rice University, Houston, Texas
- Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, Houston, Texas; and
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Piccoli GB, Trabace T, Chatrenet A, Carranza de La Torre CA, Gendrot L, Nielsen L, Fois A, Santagati G, Saulnier P, Panocchia N. New Intravenous Calcimimetic Agents: New Options, New Problems. An Example on How Clinical, Economical and Ethical Considerations Affect Choice of Treatment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E1238. [PMID: 32075103 PMCID: PMC7068561 DOI: 10.3390/ijerph17041238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 02/10/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Dialysis treatment is improving, but several long-term problems remain unsolved, including metabolic bone disease linked to chronic kidney disease (CKD-MBD). The availability of new, efficacious but expensive drugs (intravenous calcimimetic agents) poses ethical problems, especially in the setting of budget limitations. METHODS Reasons of choice, side effects, biochemical trends were discussed in a cohort of 15 patients (13% of the dialysis population) who stared treatment with intravenous calcimimetics in a single center. All patients had previously been treated with oral calcimimetic agents; dialysis efficacy was at target in 14/15; hemodiafiltration was employed in 10/15. Median Charlson Comorbidity Index was 8. The indications were discussed according to the principlist ethics (beneficience, non maleficience, justice and autonomy). Biochemical results were analyzed to support the clinical-ethical choices. RESULTS In the context of a strict clinical and biochemical surveillance, the lack of side effects ensured "non-maleficence"; efficacy was at least similar to oral calcimimetic agents, but tolerance was better. Autonomy was respected through a shared decision-making model; all patients appreciated the reduction of the drug burden, and most acknowledged better control of their biochemical data. The ethical conflict resides in the balance between the clinical "beneficience, non-maleficience" advantage and "justice" (economic impact of treatment, potentially in attrition with other resources, since the drug is expensive and included in the dialysis bundle). The dilemma is more relevant when a patient's life expectancy is short (economic impact without clear clinical advantages), or when non-compliance is an issue (unclear advantage if the whole treatment is not correctly taken). CONCLUSIONS In a context of person-centered medicine, autonomy, beneficence and non-maleficence should weight more than economic justice. While ethical discussions are not aimed at finding "the right answer" but asking "the right questions", this example can raise awareness of the importance of including an ethical analysis in the choice of "economically relevant" drugs.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, 10124 Torino, Italy
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | - Tiziana Trabace
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | - Antoine Chatrenet
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | | | - Lurlinys Gendrot
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | - Louise Nielsen
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | - Antioco Fois
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | - Giulia Santagati
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | - Patrick Saulnier
- Statistical laboratory, University of Angers, 49035 Angers, France;
| | - Nicola Panocchia
- Nephrology Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy;
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Spoendlin J, Paik JM, Tsacogianis T, Kim SC, Schneeweiss S, Desai RJ. Cardiovascular Outcomes of Calcium-Free vs Calcium-Based Phosphate Binders in Patients 65 Years or Older With End-stage Renal Disease Requiring Hemodialysis. JAMA Intern Med 2019; 179:741-749. [PMID: 31058913 PMCID: PMC6503544 DOI: 10.1001/jamainternmed.2019.0045] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Guidelines restricting use of calcium-based phosphate binders in all patients with end-stage renal disease owing to their potential contribution to increased cardiovascular risk shifted prescribing from calcium acetate toward the costlier sevelamer carbonate products. OBJECTIVE To compare cardiovascular events and mortality between patients with end-stage renal disease (ESRD) undergoing hemodialysis receiving sevelamer vs calcium acetate in real-world practice. DESIGN, SETTING, AND PARTICIPANTS An observational cohort study was conducted using the United States Renal Data System linked to Medicare claims data (May 1, 2012, to December 31, 2013). Data analysis was performed from October 2017 to September 2018. Participants included patients 65 years or older with ESRD within 180 days after starting hemodialysis (sevelamer, 2647; calcium acetate, 2074). EXPOSURES New use of sevelamer (calcium-free phosphate binder) vs calcium acetate (calcium-based phosphate binder). MAIN OUTCOMES AND MEASURES Hazard ratios (HRs) with 95% CIs were estimated for fatal or nonfatal cardiovascular events (myocardial infarction or ischemic stroke: primary outcome) and all-cause mortality (secondary outcome) using Cox proportional hazards regression with fine stratification on the propensity score to control for potential confounders, including phosphorus and calcium levels. RESULTS After propensity score weighting, 2639 patients initiating sevelamer treatment (1184 men [44.9%]; mean [SD] age, 75.6 [6.9] years) and 2065 patients initiating calcium acetate treatment (930 men [45.0%]; mean [SD] age, 75.5 [7.1] years) were included in the analysis. Crude incidence rates (IRs) for cardiovascular events of 458 per 1000 person-years for sevelamer and 464 per 1000 person-years for calcium acetate were observed. After propensity score fine-stratification weighting, HRs of 0.96 (95% CI, 0.84-1.10) for cardiovascular events were observed. Results were consistent within subgroups of age (<75 y: primary outcome, HR, 1.02; 95% CI, 0.85-1.24; vs ≥75 years: primary outcome, HR, 0.83; 95% CI, 0.69-1.01) and sex (primary outcome in men: HR, 1.02; 95% CI, 0.83-1.26). CONCLUSIONS AND RELEVANCE The results of the study do not suggest increased cardiovascular safety of sevelamer in the routine clinical practice of patients with ESRD compared with calcium acetate; this study's findings suggest that well-designed, long-term, randomized clinical trials are needed.
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Affiliation(s)
- Julia Spoendlin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Julie M Paik
- Renal Section, Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,New England Geriatrics Research Education and Clinical Center, Veterans Affairs Boston Healthcare System, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - T Tsacogianis
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Abstract
Since 2011, the Centers for Medicare & Medicaid Services has provided reimbursement for renal dialysis services furnished to Medicare beneficiaries through a bundled payment system known as the Prospective Payment System. Medications that have no injectable equivalent, known as "oral-only medications," are currently excluded from the bundle and are paid separately through Medicare Part D. Thus, before the development of etelcalcetide, the first injectable calcimimetic, calcimimetics were reimbursed outside the bundle. Etelcalcetide's introduction and approval for use in Medicare triggered a transition payment for a minimum of 2 years that will eventually result in the incorporation of calcimimetics into the dialysis bundle. Consequently, providers may face incentives to reduce calcimimetic use when the transition period has expired. The complexity of bone-mineral management in conjunction with the paucity of evidence-based recommendations in this area makes it difficult to predict the impact of this transition. Because these medications are expensive, a poor transition could have financial ramifications for dialysis organizations and potentially patient health. To ensure that patients are not adversely affected, it is critical that Medicare incorporate these medications into the bundle carefully, with close monitoring of outcomes.
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Affiliation(s)
- Eugene Lin
- Division of Nephrology and Hypertension, Department of Medicine, University of Southern California, Los Angeles, CA; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA; Kidney Research Center, University of Southern California/University Kidney Research Organization, Los Angeles, CA.
| | - Suzanne Watnick
- Division of Nephrology and Hypertension, Department of Medicine, University of Washington, Seattle, WA; Northwest Kidney Centers, Seattle, WA
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Negrea L. Active Vitamin D in Chronic Kidney Disease: Getting Right Back Where We Started from? KIDNEY DISEASES (BASEL, SWITZERLAND) 2019; 5:59-68. [PMID: 31019920 PMCID: PMC6465695 DOI: 10.1159/000495138] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 11/01/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The vitamin D system is essential for optimal health in humans. Circulating calcitriol, a key metabolite in maintaining calcium and phosphorus homeostasis, is produced in the kidney. In kidney failure, calcitriol levels progressively decrease, contributing to the development of renal secondary hyperparathyroidism (SHPT). SUMMARY For years, SHPT had a central role in the disturbed mineral metabolism of renal patients. As calcitriol deficiency contributes to SHPT development, treatment with calcitriol or other compounds able to activate the vitamin D receptor (VDR) was one of the mainstays of therapy for renal patients in the last 40 years. In this review, we discuss how the treatment with VDR activators (VDRA) evolved during this time in the United States, as well as the main factors responsible for these changes. KEY MESSAGES Management of SHPT with VDRA in renal patients has undergone a few paradigm shifts over the last 40 years. When treating SHPT, the newly developed therapies as well as VDRA need to be carefully considered and used appropriately. Nephrologists need to use an integrated approach that avoids excessive use of VDRA, ensures replenishment of vitamin D stores, and avoids hypercalcemia and hyperphosphatemia.
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Affiliation(s)
- Lavinia Negrea
- Renal Division, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Fuller DS, Xing S, Belozeroff V, Yehoshua A, Morgenstern H, Robinson BM, Rubin RJ, Bhatt N, Pisoni RL. Variability in Cinacalcet Prescription across US Hemodialysis Facilities. Clin J Am Soc Nephrol 2019; 14:241-249. [PMID: 30665922 PMCID: PMC6390908 DOI: 10.2215/cjn.09550818] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 12/12/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Calcimimetic drugs used to treat secondary hyperparathyroidism are being considered for inclusion in the Medicare ESRD Prospective Payment System bundle after an evaluation period. Understanding of utilization patterns of calcimimetics across dialysis facilities may help align financial incentives with clinical objectives. Our study's purpose was to describe the distribution of cinacalcet prescription across United States hemodialysis facilities and to explore factors that may influence cinacalcet utilization. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used monthly cross-sectional data from the Dialysis Outcomes and Practice Patterns Study in 2014 to characterize the distribution of cinacalcet prescription across 203 United States hemodialysis facilities (10,521 patients). On the basis of associations with parathyroid hormone levels from patient-level analyses, we used linear mixed-effects regressions to estimate the associations between three facility-level exposures (black race, <65 years old, and having ≥3 years on dialysis [vintage]) and the prevalence of cinacalcet prescription, adjusting for facility- and patient-level potential confounders. RESULTS The mean percentage of patients in each facility with cinacalcet prescription was 23% in June 2014 (median, 22%; interquartile range, 13%-30%). Adjusted for facility-level and nonexposure patient-level variables, the difference in prevalence of cinacalcet prescription between facilities with the highest and lowest quartiles of percentage of black patients was 7.8% (95% confidence interval [95% CI], 0.8% to 14.8%; P for trend =0.03). The adjusted prevalence difference was 7.3% for the percentage of patients aged <65 years (95% CI, -0.1% to 14.7%; P for trend =0.06) and 11.9% for the percentage of patients with ≥3 years of dialysis (95% CI, 2.4% to 21.4%; P for trend =0.02). These associations changed appreciably, becoming much weaker or even reversing, after further adjusting for the patient-level exposure variables. CONCLUSIONS Facilities treating more patients who are black, under age 65 years, and having dialysis vintage ≥3 years have higher average levels of cinacalcet prescription. However, these differences were strongly attenuated after accounting for the unbalanced distributions of these patient case-mix variables.
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Affiliation(s)
| | - Shan Xing
- Global Health Economics, Amgen, Inc., Thousand Oaks, California
| | | | - Alon Yehoshua
- Global Health Economics, Amgen, Inc., Thousand Oaks, California
| | - Hal Morgenstern
- Departments of Epidemiology and
- Environmental Health Sciences, School of Public Health, and
- Department of Urology, Medical School, University of Michigan, Ann Arbor, Michigan; and
| | | | - Robert J. Rubin
- Division of Nephrology and Hypertension, Georgetown University, Washington, DC
| | - Nisha Bhatt
- Global Health Economics, Amgen, Inc., Thousand Oaks, California
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Seethapathy H, Nigwekar SU. Medication Prescription Patterns for Secondary Hyperparathyroidism: More Questions than Answers. Clin J Am Soc Nephrol 2019; 14:178-179. [PMID: 30665921 PMCID: PMC6390906 DOI: 10.2215/cjn.15081218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Harish Seethapathy
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Sagar U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Awan AA, Thomas SS, Erickson KF. Making Policy in the Dark: The Use of Activated Vitamin D Under Bundled Payments for Dialysis Care. Am J Kidney Dis 2018; 72:161-163. [PMID: 30037474 DOI: 10.1053/j.ajkd.2018.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 04/28/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Ahmed A Awan
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX
| | - Sandhya S Thomas
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX; Michael E. Debakey Veterans Affairs Medical Center, Houston, TX
| | - Kevin F Erickson
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX; Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, Houston, TX; Baker Institute for Public Policy, Rice University, Houston, TX.
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