Peritoneal Dialysis Use Increases After Medicare Payment Reform

Nancy A. Melville

November 28, 2019

Use of home-based peritoneal dialysis in patients with end-stage kidney disease (ESKD) has increased in the United States following the implementation of important changes in the Medicare payment structure for dialysis treatment n 2011, new research shows.

But rates are still relatively low compared with other Western nations.

The study showed around a 50% increase in home dialysis after the payment reforms compared with before, but only around 12% of patients in the United States started dialysis at home. Rates of home dialysis are much higher in other nations, including Hong Kong (70%), Mexico (51%), New Zealand (30%), Sweden (21%), and Canada (19%).

"Our study found that more patients are now starting, staying on, and switching to peritoneal dialysis than before Medicare's prospective payment system was implemented," Caroline E. Sloan, MD, of Duke University Medical School, Durham, North Carolina, and colleagues report in their study published online November 21 in the Clinical Journal of the American Society of Nephrology.

"This growth in peritoneal dialysis use occurred without a substantial increase in transfers to hemodialysis, achieving a secondary goal of payment reform," they add.

The Trump administration supports the move to home-based dialysis as part of an executive order to improve kidney disease care issued this summer. By 2025, 80% of patients newly diagnosed with ESKD should receive home dialysis or kidney transplants, officials say.

Senior author Virginia Wang, PhD, notes a variety of factors explain why the United States lags behind other countries in use of peritoneal dialysis.  

These include a lack of "availability of dialysis facilities providing peritoneal dialysis services, which our...team has also studied, clinicians sufficiently educated and trained to treat peritoneal dialysis, patient awareness and education of all modality options, and healthcare financing structures to support it."

"It may seem a bit of a chicken versus egg scenario, but such movement needs to start somewhere and also requires systemic change," she told Medscape Medical News.

Peritoneal Dialysis Suitable for Half of Patients With ESKD

Home-based peritoneal dialysis is associated with greater patient-reported quality of life, lower rates of complications, and lower societal costs compared with hemodialysis, although it is not without its challenges.

Nevertheless, only 7.6% of patients with ESKD were using peritoneal dialysis in the United States in 2010, according to one estimate.

"US nephrologists have previously reported that peritoneal dialysis is an appropriate therapy for roughly half of their patients," said Wang, also of Duke University School of Medicine. "This is a striking contrast to actual utilization rates in the United States and what we know about patient preferences for treatment."

In 2011, the Centers for Medicare and Medicaid Services implemented the ESKD prospective payment system, which allowed for bundling of dialysis treatment into a single payment, including dialysis, medications, and ancillary services.

The system also included training for home dialysis.

Although previous studies have shown a modest increase in the proportion of facilities offering peritoneal dialysis between 2006 and 2013 from 36% to 42%, Duke researchers sought to look at long-term patterns of use before and after the Medicare changes.

For the study, they identified 619,126 patients with incident ESKD who initiated dialysis at Medicare-certified facilities before (2006-2010) and after (2011-2013) the dialysis payment changes.

50% Increase in Peritoneal Dialysis After Payment Reform

The team found that the early use of peritoneal dialysis, defined as use within the first 90 days of initiating dialysis, increased from 9.4% prior to the payment changes to 12.6% afterward.

Meanwhile, the use of late peritoneal dialysis, defined as between 91 days and 2 years after initiating dialysis, increased during the same period from 12.1% to 16.1%.

After adjusting for factors including age, sex, race, ethnicity, US region, and employment status, the Medicare payment change was associated with an increased early use of peritoneal dialysis (OR, 1.51; P < .001) and late peritoneal dialysis (OR, 1.47; P < .001).

A subanalysis showed that part of the increase in late peritoneal dialysis use resulted in a switch from hemodialysis among those who did not have earlier peritoneal dialysis experience (OR, 1.59; P < .001). And there was a decrease in switching from peritoneal dialysis to hemodialysis among those with early peritoneal experience (OR, 0.92; P = .004).

"The observed growth in early peritoneal experience and late peritoneal use, and the small reduction in peritoneal-to-hemodialysis switches suggests that the prospective payment system did not induce inappropriate referrals to peritoneal dialysis," the authors say.

"This finding highlights the potential for more growth in peritoneal dialysis use in the coming years," they stress.

Financial Incentives Alone Not Enough to "Move the Needle"

Wang stressed to Medscape Medical News that "financial incentives alone will not be sufficient for moving the needle on peritoneal dialysis use."

"Investment in renal workforce development and training across all treatment modalities, earlier detection of kidney disease, and preparation for kidney failure [are needed]," she said.

"Studies have shown a patient preference for peritoneal dialysis if they are informed of it, but a significant number are often not told about peritoneal dialysis as a treatment option," she explained.

Wang and coauthors note, however, that peritoneal dialysis use may have accelerated since the end of the study period in 2013.

"It will be important to evaluate this trend in the longer-term to determine whether, when, and where payment reform encourages dialysis use that is more closely aligned with patient preference and clinical appropriateness," they conclude.

CJASN. Published online November 21, 2019. Full text

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