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Randomized Controlled Trial
. 2023 Feb 1;6(2):e230806.
doi: 10.1001/jamanetworkopen.2023.0806.

Association of the End-Stage Renal Disease Treatment Choices Payment Model With Home Dialysis Use at Kidney Failure Onset From 2016 to 2022

Kirsten L Johansen  1   2 , Shuling Li  1 , Jiannong Liu  1 , Eric D Weinhandl  1   2   3 , David T Gilbertson  1   2 , Iris Kou  1 , Christopher Knapp  1 , James B Wetmore  1   2
Affiliations
Randomized Controlled Trial

Association of the End-Stage Renal Disease Treatment Choices Payment Model With Home Dialysis Use at Kidney Failure Onset From 2016 to 2022

Kirsten L Johansen et al. JAMA Netw Open. .

Abstract

Importance: The Centers for Medicare & Medicaid Services designed a mandatory payment model to incentivize home dialysis use: the End-Stage Renal Disease Treatment Choices (ETC). Outpatient dialysis facilities and health care professionals providing nephrology services were randomly assigned to ETC participation at the hospital referral region level.

Objective: To assess the association between ETC and home dialysis use in the incident dialysis population in its first 18 months of implementation.

Design, setting, and participants: A cohort study with controlled, interrupted time series analysis of the US End-Stage Renal Disease Quality Reporting System database was conducted, using generalized estimating equations. All adults initiating home-based dialysis in the US between January 1, 2016, and June 30, 2022, without a prior kidney transplant were included in the analysis.

Exposures: Prior to vs after ETC onset in January 1, 2021, and random assignment to ETC participation of facilities and health care professionals involved in patient care.

Main outcomes and measures: Percentage of patients started on incident home dialysis and yearly change in percentage initiating home dialysis.

Results: A total of 817 177 adults initiated home dialysis during the study period, of whom 750 314 were included in the study cohort. The cohort included 41.4% women; 26.2% of the patients were Black, 17.4% were Hispanic, and 49.1% were White. Approximately half (49.6%) of the patients were aged at least 65 years. A total of 31.2% received care from health care professionals assigned to ETC participation, and 33.6% had Medicare fee-for-service coverage. Overall, home dialysis use increased from 10.0% in January 2016 to 17.4% in June 2022. Home dialysis use increased more in ETC markets than in non-ETC markets after January 2021 (by 1.07%; 95% CI, 0.16%-1.97%). The rate of increase in home dialysis use in the entire cohort nearly doubled after January 2021 to 1.66% per year (95% CI, 1.14%-2.19%) compared with before 2021, when the rate was 0.86% per year (95% CI, 0.75%-0.97%), but the difference in rate of increase in home dialysis use was not significant between ETC and non-ETC markets.

Conclusions and relevance: This study noted that, although the overall rate of dialysis use at home was greater after ETC implementation, the increase occurred more among patients in ETC markets than among those in non-ETC markets. These findings suggest that federal policy and financial incentives affected care for the entire incident dialysis population in the US.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Johansen reported receiving personal fees from GSK for participation on a steering committee; personal fees from Vifor as a member of an advisory board outside the submitted work; and is a practicing nephrologist whose practice is participating in the End-Stage Renal Disease Treatment Choices payment model. Dr Liu reported receiving grants from the National Institutes of Health during the conduct of the study. Dr Weinhandl reported being an employee of Satellite Healthcare (December 1, 2021, outside the submitted work), which is a dialysis provider and operates some dialysis facilities in ETC markets (and others in non-ETC markets). No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Study Flow Diagram
ETC indicates End-Stage Renal Disease Treatment Choices payment model.
Figure 2.
Figure 2.. Monthly Proportion of Patients Starting Incident Dialysis Receiving Home Dialysis by End-Stage Renal Disease Treatment Choices (ETC) Assignment of Facilities and Health Care Professionals Providing Nephrology Services
The black vertical line indicates the start of ETC implementation.
See this image and copyright information in PMC

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