Eugene Lin1, Khristina I Lung2, Glenn M Chertow3, Jay Bhattacharya4, Darius Lakdawalla5. 1. Division of Nephrology, Department of Medicine, University of Southern California, Los Angeles, CA, USA; Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA; Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA; Kidney Research Center, University Kidney Research Organization, Los Angeles, CA, USA. Electronic address: eugene.lin@med.usc.edu. 2. Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA. 3. Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA; Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA. 4. Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA; Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA. 5. Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA; Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA; School of Pharmacy, University of Southern California, Los Angeles, CA, USA.
Abstract
OBJECTIVES: Policy makers have suggested increasing peritoneal dialysis (PD) would improve end-stage kidney disease (ESKD) outcomes and reduce Medicare spending compared with hemodialysis (HD). We compared mortality, hospitalizations, and Medicare spending between PD and HD among uninsured adults with incident ESKD. METHODS: Using an instrumental variable design, we exploited a natural experiment encouraging PD among the uninsured. Uninsured patients usually receive Medicare at dialysis month 4. For those initiating PD, Medicare covers the first 3 dialysis months, including predialysis services in the calendar month when dialysis started. Starting dialysis later in a calendar month increases predialysis coverage that is essential for PD catheter placements. The policy encourages PD incrementally when ESKD develops later in the month. Dialysis start day appears to be unrelated to patient characteristics and effectively "randomizes patients" to dialysis modality, mitigating selection bias. RESULTS: Starting dialysis later in the month was associated with an increased PD uptake: every week later in the month was associated with an absolute increase of 0.8% (95% confidence interval [CI] 0.6%-0.9%) at dialysis day 1 and 0.5% (95% CI 0.3%-0.7%) at dialysis month 12. We observed no significant absolute difference between PD and HD for 12-month mortality (-0.9%, 95% CI -3.3% to 0.8%), hospitalizations during months 7 to 12 (-0.05, 95% CI -0.20 to 0.07), and Medicare spending during months 7 to 12 (-$702, 95% CI -$4004 to $2909). CONCLUSIONS: In an instrumental variable analysis, PD did not result in improved outcomes or lower costs than HD.
OBJECTIVES: Policy makers have suggested increasing peritoneal dialysis (PD) would improve end-stage kidney disease (ESKD) outcomes and reduce Medicare spending compared with hemodialysis (HD). We compared mortality, hospitalizations, and Medicare spending between PD and HD among uninsured adults with incident ESKD. METHODS: Using an instrumental variable design, we exploited a natural experiment encouraging PD among the uninsured. Uninsured patients usually receive Medicare at dialysis month 4. For those initiating PD, Medicare covers the first 3 dialysis months, including predialysis services in the calendar month when dialysis started. Starting dialysis later in a calendar month increases predialysis coverage that is essential for PD catheter placements. The policy encourages PD incrementally when ESKD develops later in the month. Dialysis start day appears to be unrelated to patient characteristics and effectively "randomizes patients" to dialysis modality, mitigating selection bias. RESULTS: Starting dialysis later in the month was associated with an increased PD uptake: every week later in the month was associated with an absolute increase of 0.8% (95% confidence interval [CI] 0.6%-0.9%) at dialysis day 1 and 0.5% (95% CI 0.3%-0.7%) at dialysis month 12. We observed no significant absolute difference between PD and HD for 12-month mortality (-0.9%, 95% CI -3.3% to 0.8%), hospitalizations during months 7 to 12 (-0.05, 95% CI -0.20 to 0.07), and Medicare spending during months 7 to 12 (-$702, 95% CI -$4004 to $2909). CONCLUSIONS: In an instrumental variable analysis, PD did not result in improved outcomes or lower costs than HD.
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