Trends in Peritoneal Dialysis Use in the United States after Medicare Payment Reform

Abstract

Background and objectives: Peritoneal dialysis (PD) for ESKD is associated with similar mortality, higher quality of life, and lower costs compared with hemodialysis (HD), but has historically been underused. We assessed the effect of the 2011 Medicare prospective payment system (PPS) for dialysis on PD initiation, modality switches, and stable PD use.

Design, setting, participants, & measurements: Using US Renal Data System and Medicare data, we identified all United States patients with ESKD initiating dialysis before (2006-2010) and after (2011-2013) PPS implementation, and observed their modality for up to 2 years after dialysis initiation. Using logistic regression models, we examined the associations between PPS and early PD experience (any PD 1-90 days after initiation), late PD use (any PD 91-730 days after initiation), and modality switches (PD-to-HD or HD-to-PD 91-730 days after initiation). We adjusted for patient, dialysis facility, and regional characteristics.

Results: Overall, 619,126 patients with incident ESKD received dialysis at Medicare-certified facilities, 2006-2013. Observed early PD experience increased from 9.4% before PPS to 12.6% after PPS. Observed late PD use increased from 12.1% to 16.1%. In adjusted analyses, PPS was associated with increased early PD experience (odds ratio [OR], 1.51; 95% confidence interval [95% CI], 1.47 to 1.55; P<0.001) and late PD use (OR, 1.47; 95% CI, 1.45 to 1.50; P<0.001). In subgroup analyses, late PD use increased in part due to an increase in HD-to-PD switches among those without early PD experience (OR, 1.59; 95% CI, 1.52 to 1.66; P<0.001) and a decrease in PD-to-HD switches among those with early PD experience (OR, 0.92; 95% CI, 0.87 to 0.98; P=0.004).

Conclusions: More patients started, stayed on, and switched to PD after dialysis payment reform. This occurred without a substantial increase in transfers to HD.

Keywords: end stage kidney disease; peritoneal dialysis; prospective payment system.

Graphical abstract

Figure 1.

Unadjusted early PD experience, late PD use, and switches from HD to PD increased after implementation of the 2011 PPS. (Panel A) Use before PPS (2006–2010), N=387,115. (Panel B) Use after PPS (2011–2013), N=232,011. After ESKD diagnosis, patients could initiate dialysis with PD or HD. After the 90-day initiation period, patients could remain on their initial dialysis modality, or switch to the other modality. A minority of patients who attempted PD in the first 90 days but were identified as HD users at the start of the late use observation period (91–730 days after dialysis initiation) remained on HD during this period. Numbers of patients and percentages are presented. Percentages may not add up to 100%, due to rounding. HD, hemodialysis; PD, peritoneal dialysis; PPS, Medicare prospective payment system for dialysis.

Figure 2.

Adjusted results: Estimated rates of early PD experience, late PD use and switches from HD to PD increased after the PPS, while switches from PD to HD declined modestly. (Panel A) Early PD experience reflects any PD use in the first 90 days of dialysis initiation and increased over the study period. (Panel B) Late PD use reflects stable PD use (≥60 consecutive days) in days 91–730 after dialysis initiation and also increased during 2006–2013. (Panel C) Dialysis modality switches among the subgroup of patients without early PD experience (i.e., only early HD experience), who switched to PD in days 91–730 after dialysis initiation, increased during 2006–2013. The subgroup of patients with early PD experience, who later switched to HD in days 91–730 after dialysis initiation, decreased during 2006–2013. A minority of patients with early PD experience were HD users at the start of the late use period and remained on HD days 91–730 after dialysis initiation; however, this misclassification did not affect our results. All estimates were generated from predicted probabilities over the pre- and post-PPS periods and in individual years, using appropriate intercept and slope parameters with fixed values of covariates centered at mean values. Note: The error bars in the figure panels display annual model-estimated PD use rate 95% confidence intervals which, in some cases, are small. HD, hemodialysis; PD, peritoneal dialysis; PPS, Medicare prospective payment system for dialysis.