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Abstract: PO1259

Comparing Mortality of Peritoneal and Hemodialysis Patients in an Era of Medicare Reform

Session Information

Category: Dialysis

  • 703 Dialysis: Peritoneal Dialysis

Authors

  • Wang, Virginia, Duke Univ, Durham, North Carolina, United States
  • Coffman, Cynthia, Duke Univ, Durham, North Carolina, United States
  • Sanders, Linda L., Duke Univ, Durham, North Carolina, United States
  • Hoffman, Abby, Duke Univ, Durham, North Carolina, United States
  • Sloan, Caroline E., Duke Univ, Durham, North Carolina, United States
  • Lee, Shoou-Yih Daniel, Univ Mich, Ann Arbor, Michigan, United States
  • Hirth, Richard A., Univ Mich, Ann Arbor, Michigan, United States
  • Maciejewski, Matthew L., Durham VAHCS, Durham, North Carolina, United States
Background

Medicare’s 2011 prospective payment system (PPS) encouraged the expansion of peritoneal dialysis (PD), which is preferred by many patients and less costly than in-center hemodialysis (HD). Prior studies have shown PD to be associated with lower or equivalent mortality to HD. Expansion of PD services after the PPS may change the relative mortality of PD and HD if PD is increasingly used by sicker patients. This study revisits the comparative risk of mortality between PD and HD modalities in cohorts of patients spanning Medicare PPS.

Methods

From the US Renal Data System, we compared 2-year all-cause mortality in a cohort of incident dialysis patients in 2006-2013. Patients were censored at renal transplant or the end of the 2-year follow-up. Baseline characteristics of HD and PD patients were assessed via standardized differences and Kaplan-Meier curves. To compare HD and PD 2-year survival, a Cox proportional hazards model was fit using inverse probability of treatment weights (IPTW, generated from patient demographic and clinical characteristics) by incident year, adjusting for patient and dialysis market characteristics.

Results

PD use in the first 90 days increased from 9.5% of incident patients in 2006 to 13.6% in 2013. Crude 2-year mortality was 16.7% for PD and 27.6% for HD. There were no differences in patient characteristics between pre- and post-policy cohorts. In IPTW survival analysis across all incident year cohorts, no differences in 2-year mortality were found for those who attempted PD in the first 90-days of dialysis compared to patients receiving HD (example: HR, 0.93; 95% CI, 0.84 to1.04 for 2006 incident cohort). Mortality differences between PD and HD did not change over time (p=0.23).

Conclusion

Growth in PD initiation over time occurred without changing the patient mix towards sicker patients. After accounting for confounding, we found no evidence of mortality differences between PD and HD before and after payment reform. These findings suggest that Medicare PPS improved the value of dialysis care such that PD service use increased without adversely affecting patient mortality. Still, PD uptake in the US still lags that of many countries. Future policy initiatives may be needed to continue to increase clinically appropriate PD uptake.

Funding

  • NIDDK Support