Transcript OSMOTIC 4/98 - ESRD Networks

OPTIMIZING OUTCOMES ON
PERITONEAL DIALYSIS:
John Burkart, M.D.
Wake Forest University Baptist Medical Center
Winston Salem, NC USA
07/12/2008
CONFLICT OF INTEREST
John Burkart

Advisory Boards ---

Grants ----------------
Baxter, NxStage, Genzyme,
CMS
NIH, Baxter, Genzyme,
Abbott, NxStage, Watson

Honoraria -----------
Baxter, Fresenius

Chief Medical Officer
14 dialysis units
(CHD, PD, HHD)
CONFLICT OF INTEREST






Passion for home dialysis (PD and HHD)
Course director PDUs
Involved in Frequent HD study (nocturnal)
Medical director 14 units (until 2008 CFC)
In the Wake Forest Outpatient Units about 13% of
patients on Home dialysis
About 30% of my patients on Home Dialysis
TOPICS TO BE COVERED



Outcomes for PD are improving – medical
data suggests we should do more PD!
Given medical data that tends to favor PD,
why are we not doing more PD?
Recommendations
TOPICS TO BE COVERED



Outcomes for PD are improving – medical
data suggests we should do more PD!
Given medical data that tends to favor PD,
why are we not doing more PD?
Recommendations



Attempted to randomize patients to PD or HD
Eligible patients were given extensive informed consent
Informed consent included explanation of PD and HD
PATIENT MODALITY CHOICE:
Lessons from an Attempted Prospective Randomized Trial
Agreed to Randomization
Wanted HD
Wanted PD
400
350
300
250
200
150
100
50
0
Agreed to
Randomization
Wanted HD
Wanted PD
After 3 ½ years, only 38/735 eligible agreed to randomization!
Korevaar JC et al KI 2003; 64:222-228
ATTEMPTED PRCT TO EVALUATE
SURVIVAL ON PD vs. HD
800
700
600
500
400
# pts
300
200
100
0
# eligible




773 eligible patients
Only 38 were randomized
Results underpowered
Survival better on PD
Korevaar JC et al KI 2003; 64:222-228
WHAT DO OBSERVATIONAL
COHORT STUDIES SHOW US?
Caveats, limitations thereof
acknowledged
COMPARISON OF HD AND PD
SURVIVAL IN THE NETHERLANDS
Methods:




20,687 patients started RRT between 1/1/87 and 12/31/02
Excluded data on: Transplant first 90 days; HD unit < 20
pts or PD unit < 5 pts; < 18 years old
Final analysis – 47 centers; 16,643 total: 10,841 on HD,
5802 on PD.
Analysis univariate and multivariate Cox model
Liem et al, KI 2007; 71:153-158
UNAJUSTED PATIENT SURVIVAL
PD vs HD - Netherlands
Liem et al, KI 71:153-158, 2007
HD and PD Comparison of Adjusted
Mortality Rates According to the
Duration of Dialysis
METHODS:






All consecutive new RRT starts
Survived at least 3 months on HD (baseline)
742/947 HD patients, 480/582 PD patients
Follow up till 9/1/02
Analysis both in As-Treated (AT) and intend to treat (ITT)
manner
For AT analysis, deaths assigned to original Rx if occurred
within 60 days of transfer
Termorshuizen et al JASN 2003; 14:2851-2860
RELATIVE RISK OF DEATH
HD vs PD
Termorshuizen et al. JASN 14: 2851-2860; 2003
SURVIVAL RISK ON ESRD
HD vs PD
METHODS:


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Incidence data from US medicare patients
initiating dialysis between 1995 and 2000
398,940 patients
Proportional hazards regression
Stratified by cause of ESRD, presence of
comorbidities, age
Proprtional and non-porportional hazards methods
were used to estimate relative risk of HD:PD
Vonesh et al KI 2004; 66:2389-2401
RELATIVE RISK OF DEATH
PD vs. HD by Diabetic Status – No Comorbidity
Vonesh et al KI 2004; 66:2389-2401
Vonesh et al KI 2004; 66:2389-2401
RELATIVE RISK OF DEATH
PD vs. HD by Diabetic Status – With Comorbidity
Vonesh et al KI 2004; 66:2389-2401
Vonesh et al KI 2004; 66:2389-2401
ADJUSTED FIVE YEAR
SURVIVAL
by modality & primary diagnosis
Incident dialysis patients; adjusted for age, gender, & race. ESRD patients, 1996, used as reference cohort. Modality determined on first ESRD
service date; excludes patients transplanted or dying during the first 90 days (five-year survival probabilities noted in parentheses).
Fig 6.3 USRDS Annual report AJKD 2006
First-year mortality rate:
with basic vs. composite adjustments
Figure ei.1
Incident dialysis
patients. Basic
adjustment: age,
gender, race, &
primary diagnosis.
Composite adjustment:
age, gender, race,
primary diagnosis,
comorbidities, BMI,
hemoglobin, & eGFR.
Comorbidities &
laboratory information
from the Medical
Evidence form.
Incident dialysis
patients, 2004, used as
reference cohort.
2007 USRDS Report
ADJUSTED FIVE-YEAR
SURVIVAL:
by first modality
USRDS 2007 Figure p.25
Point where relative risk crosses has moved to right!
91-95
96-00
Incident dialysis patients & patients receiving a first transplant in the calendar year, 1991–1995 & 1996–2000 combined;
adjusted for age, gender, race, & primary diagnosis. Incident ESRD patients, 1996, used as reference cohort. Dialysis
patients are followed from day 90 after initiation; transplant patients are followed from the transplant date.
RELATIVE RISK OF DEATH:
PD vs HD --ANZDATA
MacDonald et al. JASN 20:155-163; 2009
ANZDATA REGISRTY
Relative Risk of Death PD vs HD
MacDonald et al. JASN 20:155-163; 2009
PERITONITIS RATES ARE
HIGH IN ANZDATA
Johnson AJKD 2009: 53:290-297
SUMMARY OF EPIDEMIOLOGICAL
OBSERVATIONAL STUDIES
Population based cohort studies suggest:
 At initiation of dialysis survival risk favors PD
 Relative risk for PD vs HD changes over time
 Survival advantage for PD less robust for:

Elderly, patients with DM or comorbidities
Survival advantage varies from country to country
 All cohorts show same trends
These are Observational cohort studies
 These studies have limitations do not establish
casuality and are hypothesis generating

Geographic variations in unadjusted incident
rates (per million population), by first modality & HSA:
PD PATIENTS, 1994-1995
Figure 4.4 (continued)
Incident ESRD
patients, by HSA,
unadjusted.
Excludes patients
residing in Puerto
Rico & the
Territories.
2007 USRDS Report
Geographic variations in unadjusted incident
rates (per million population), by first modality & HSA:
PD PATIENTS, 2004-2005
Figure 4.4 (continued)
Incident ESRD
patients, by HSA,
unadjusted.
Excludes patients
residing in Puerto
Rico & the
Territories.
2007 USRDS Report
Adjusted admissions for principal
diagnoses, by modality
Figure 6.5 (Volume 2)
Period prevalent ESRD patients; adjusted for age, gender, race, & primary diagnosis. ESRD patients, 2005, used as
reference cohort.
INFECTION RELATED PATIENT
TRANSFER FROM PD to HD
DECREASING
8
Patient Transfer (%)
7
6
5
1999
2000
2001
4
3
2
1
0
All
New to Dialysis
Transfer from HD
Guo, Mujais. Kidney Int. 2003;64 (suppl 88):S1-S10.
TOPICAL MUPIROCIN
REDUCES ESI/PERITONITIS
0.7
0.6
0.5
0.61
P<0.001
Control
Mupirocin
P=0.003
0.42
0.39
0.4
0.3
P=0.19
0.19
0.2
0.075
0.1
0.047
0
ESI
Peritonitis
Catheter loss
Casey, Burkart PDI 2000
Mupirocin prophylaxis reduces
S aureus peritonitis
S aureus peritonitis/year
control
prophylaxis
0.25
0.2
0.15
0.1
0.05
0
intranasal
mupirocin
intranasal
mupirocin
exit site
mupirocin
Perez-Fontan
The Mupirocin
Study Group
Bernardini
exit site
mupirocin
Thodis
Double Blinded Randomized Trial of
Mupirocin vs Gentamicin Exit Site Cream
PERITONITIS
Gentamicin cream reduced GNR
peritonitis, compared to mupirocin
0.6
sterile
0.5
yeast
0.4
Other GN
0.3
P aerug
0.2
other Grpos
0.1
S aureus
0
mupirocin
gentacmicin
Piraino, Bernardinin - Presented at ISPD 2004 Congress
PERITONITIS USUALLY RESOLVES
WITHOUT COMPLICATIONS
% all episodes
90
CoagNS
S aureus
nP-GNR
80
70
60
50
40
30
20
10
0
Resolved
Hospital.
Catheter
Removed
Transfer
Death
Bunke et al V52;2 p524 KI 1997
Infection Rates Reduced In PD
As Innovations and Protocols Are Introduced
Peritonitis Episodes/Patient Year
1.1
1.0
Y set introduced
0.9
Double bag system
0.8
S aureus prophylaxes
introduced
0.7
0.6
Spike assist device
for cycler patients
0.5
0.4
0.3
0.2
0.1
0
83
85
87
89
91
93
95
97
99
01
03
05
Peritonitis Episodes per Dialysis Year
Bender FH et al. KI, 2006;70(S):S44-S54.
WHAT ACCESS DO YOU
HAVE IN YOUR UNIT?
Prevalent vs. Incident
PD - peritonitis
Bacteremia
WFOPD data 2004-2005
Adj. mortality rate per 100 ptyears
ADJUSTED MORTALITY AFTER FIRST
SEPTICEMIC EVENT
160
140
120
100
With sepsis
80
USRDS:
2003 ADR
60
40
Without sepsis
20
0
6
121
8
243
03
64
Months
24
85
46
0
Incident dialysis patients (90-day rule), 1996–1999 combined; adjusted for modality, age, gender, race, & primary
diagnosis. Patients with Medicare as a secondary payor or enrolled in an HMO on day 90, & those with septicemia
claims overlapping the start date of the followup period, are excluded. Reference group: patients without sepsis.
INFECTION RATES PD vs HD
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Remember 82% of all new CHD patients start with a
catheter! (USRDS 2008 report)
Infection rates higher with Tunneled vascular catheters
than with PD (peritonitis)
Bacteremia with Tunneled catheters have been increasing!
Bacteremia associated with increased RRD for 2 to 3 years
Up to 30% of patients with catheters have 1 episode of
bacteremia by 6 months!
Peritonitis almost never associated with bacteremia.
- One Size Does Not Fit All! Must Have Flexibility in Exit-Site Placement
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Presternal
Upper Abdominal
Mid-abdominal
Lower Abdominal
PD CATHETERS HAVE A HIGH
SUCCESS RATE!
Probability of Remaining Free of Mechanical Flow Obstruction
At 24 Months Significantly Increased by Newer Techniques
P < 0.0001 vs open
or basic technique
% Probability
100
99.5%
82.5%
87.2%
Open
Dissection
Basic
Laparoscopy
75
50
25
0
Advanced
Laparoscopy
Crabtree JH et al. Am Surg. 2005;71:135-143.
Cumulative probability of
multiple catheter placements
Figure 1.9 (Volume 2)
Medicare: hemodialysis
patients who initiate
dialysis at age 67 or older
during the year specified.
Includes those with
Medicare as primary payor
during the two years prior
to initiation & through the
first six months of ESRD;
pre-ESRD claims used for
months prior to initiation
date. Medstat (EGHP):
patients with first date of
regular & continuous
dialysis in 2000 or 2005,
regardless of age. Only one
year of claims prior to the
start of dialysis was
available for the 2000
cohort.
DOES PRETRANSPLANT MODALITY
INFLUENCE ALLOGRAFT OR PATIENT
SURVIVAL?

Review of USRDS Records 1990-2000, Cox model
RESULTS:

Patients transplanted from PD predicted:

3% lower risk of graft failure

6% lower risk of recipient death

Data persist even if predominant pre-transplant
modality (>50% of dialysis time was used rather than immediate)
Goldfarb-Rumyantzev et al, AJKD 46:537, 2005
PRETRANSPLANT DIALYSIS
MODALITY AND RISK OF DELAYED
GRAFT FUNCTION
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
More likely to have delayed graft function if
transplanted from HD. 50% vs 24% on PD
Mean time to being dialysis free
7.8+3.9 days PD vs 16.8+8.0 days HD
Perez FM et al. PDI 16:48-51, 1996

More likely to have delayed graft function if
transplanted from HD. 50.4% vs 23.1% on PD
Vanholder R et al. AJKD 33:934-940, 1999
MEDICAL OUTCOMES
PD vs HD - Summary
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Early survival advantage for PD
Potential for less serious Infections
with PD
Graft and Patient survival for
transplant favor use of PD
Quality of life issues – favor PD
Cost Issues – favor PD
TOPICS TO BE COVERED



Outcomes for PD are improving –
medical data suggests we should do
more PD!
Given medical data that tends to favor
PD, why are we not doing more PD?
Recommendations
PERCENTAGE OF PREVALENT
PATIENTS ON PERITONEAL DIALYSIS
BY COUNTRY
60
End of year 2000
50
40
30
20
10
0
New
Zealand
Australia
Sweden
Norway
United
States
Germany
Japan
Chile
USRDS 2002 publication
Prevalent patient counts (USRDS),
by modality: Dec 31, 2006
December 31 point
prevalent patients;
peritoneal dialysis
counts include CAPD
& CCPD only. OPTN
was created in 1986.
USRDS 2008; Figure 4.2 (Volume 2)
WHAT WAS RESPONSIBLE FOR THE
CHANGE IN TREAND IN PD
GROWTH?
 Prior to 1995 PD was growing
 In 1993 to 1996 a change in growth
 Was it due to:






Medical outcome data?
Burden of therapy?
Physician knowledge?
Expansion in HD capacity?
Lack of PD infrastructure?
Unintended financial constraints?
WHAT WAS RESPONSIBLE FOR THE
CHANGE IN TREAND IN PD
GROWTH?

Was it due to:

Medical outcome data?






Possibly but not based on recent data
Burden of therapy?
Physician knowledge?
Expansion in HD capacity?
Lack of PD infrastructure?
Unintended financial constraints?
CLINICAL PRACTICE ISSUES
RELATED TO PD
Patients need to be trained

There is a cost associated with training that is not covered
by medicare allowable training fees
There is a high “turn over” rate



Transitions are good (HD to transplant)
But patient loss may happen before investment (training)
paid back
To keep a 100 patient home unit, need to start about 50
patients/year just to stay even
Frequency of testing


PET test, 24 hour dialysate and urine collection, etc
Not always paid for by CMS
WHAT WAS RESPONSIBLE FOR THE
CHANGE IN TREAND IN PD GROWTH?

Was it do to:

Medical outcome data?


Burden of therapy?





Possibly but not based on recent data
Possibly, but recent DOQI recommendations make care easier
Physician knowledge?
Expansion in HD capacity?
Lack of PD infrastructure?
Unintended financial constraints?
Fellows’ Perceptions of PD Training
(176 Respondents)*
80%
60%
40%
20%
A.
B.
C.
D.
0%
A.
B.
C.
D.
Fellows are not comfortable initiating PD
Fellows who feel PD training is inadequate
Fellows who agree on both (A and/or B)
Fellows who are less comfortable with PD than HD
* Fellows’ perceptions of adequacy of PD training are not significantly influenced by:
years of fellowship, # of years of clinical training during fellowship, future plans,
duration of PD clinic, # of acute PD patients, # of PD catheters they placed.
PD TRAINING IN THE U.S.
METHODS:


Survey of 125 nephrology programs and 742 fellows
Responses in 62 (50%) fellowship directors, 176 (25%) fellows
RESULTS:
 32% of fellows attend an outpatient PD clinic
 52% had a PD rotation < 4 weeks in duration
 53% attended between 0 and 10 ½ day PD clinics
 24% of fellows never initiated PD
 57% initiated PD on < 5 patients
 38% felt training was inadequate
Yadlapalli et al ASN Abstract, JASN 12:2001 A1806
PRE TEST RESULTS - PDUs
METODS:
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
The ISPD – NAC has conducted about 60 three day courses on PD
Over past 5 years we have had a pre and post test
Used the same 15 (board type) questions which were adjusted over
years due to responses/feedback
PRE TEST RESULTS:



3 questions > 75% answer correctly
12 questions <75% answer correctly
7 questions < 50% answer correctly
PD and ACEDEMICS
In medical schools – fellows look up to mentors

Who are new PD protagonists?
NIH is God

Very little HIN funding for PD
Pharma issues


Studies funded by Pharma
FDA rules too restrictive
Dialysis a necessary evil – pays the bills, BUT


Medical schools lost control of units when they were
sold to chains
In many cases hard to do research in them
PD EDUCATION

Meetings have historically minimized PD education



Academia has failed PD


Have not emphasized training, Mentorship
NIH funding in PD has been minimal


One 30 minute PD talk at this 3 day meeting
No mention of PD catheter when discussing catheter problems
Hemo trial, FHD trial, ??? PD trial
FDA restrictions have hindered PD

Very difficult to get new solutions in US
WHAT WAS RESPONSIBLE FOR THE
CHANGE IN TREAND IN PD GROWTH?
Was it due to:



Medical outcome data?
Burden of therapy?
Physician knowledge?




Fellows state they feel that their PD training is
subadequate
Expansion in HD capacity?
Lack of PD infrastructure?
Unintended financial constraints?
US DIALYSIS INDUSTRY




Since mid 80’s increase in LDOs
Huge increase in HD capacity
Approach to ESRD modality choice
influenced by local/regional/national LDO
“culture”.
Marketing wars between LDOs

For example who has the highest mean Kt/V
value?
Why??????????????
DIALYSIS PROVIDERS
% PD Patients
Dialysis Provider
# Patients
# Units
# HD Patients
# HHD
patients
# PD
Patients
% PD
Patients
FMC
119,161
1,623
11,942
585
7,634
6.1%
DaVita
107,933
1,374
97,648
1,197
9,088
8.4%
DCI
12,822
204
11,791
68
963
7.5%
Renal Advantage
8,307
91
7,545
157
605
7.2%
DSI
7,999
117
7,470
32
497
6.2%
American Renal
4,300
72
3,970
10
320
7.4%
Liberty
4,040
74
3,668
52
320
7.9%
Satellite**
3,683
37
2,942
116
625
16.9%
Innovative
2,907
35
2,640
13
254
8.7%
US renal Care
2,904
55
2,645
91
168
5.7%
2008 Totals
274,056
3,682
251,261
2,321
20,474
7.47%
2007 Totals
258,501
3,453
238,873
NA
19,628
7.59%
WFUOPD
1,442
14
1,263
7
185
12.8%
Nephrology News and Issues 2008
**Many free standing home dialysis only units
My Kt/V is Higher Than Yours


Goal to maximize numbers (which
theoretically influence outcomes)
Is this realistic?
COMPARISON OF TOTAL DELIVERED
DOSE OF DIALYSIS HD:PD
ADEMEX
Index
HEMO
Low Dose High Dose Low Dose High Dose
Total Weekly
StdKt/V1
1.80
2.27
1.991
2.162
2.261
2.432
% URR
-
-
66.3%
75.2%
Weekly KPDt/V
1.62
2.13
-
-
Weekly KRRFt/V
0.18
0.14
-
-
1.
PD Weekly Kt/V = KPDt/V + KRRFt/V, HD Weekly Kt/V = 3URR
2.
Assumes UF = 2L and VPOST = 35L such that VRR=0.057, and Kt/V = 3(URR+0.057)
ADEMEX: SURVIVAL
Primary Outcome
Various Sub-group analyses also showed no effect of PD clearances
on outcomes.
Paniagua, J Am Soc Nephrol,
2002
THE HEMO STUDY –
Survival by Dose Group
p = NS
Eknoyan et al, NEJM 2002
IT’S THE NUMBERS STUPID!
Oh Really?


There are inherent differences in biochemical
parameters between PD and CHD patients
DO these differences in general mean something
in terms of:



QOL?
Survival?
DO these differences in some way subtly influence
“culture” and “availability” of modality in LDOs?
MODALITY EDUCATION

Does it happen?



Once when sick?
Repeatedly over time?
How is it done?


Biased
All options given?
PATIENT MODALITY CHOICE:
Lessons from an Attempted Prospective Randomized Trial
Agreed to Randomization
Wanted HD
Wanted PD
400
350
300
250
200
150
100
50
0
Agreed to
Randomization
Wanted HD
Wanted PD
After 3 ½ years, only 38/735 eligible agreed to randomization!
Korevaar JC et al KI 2003; 64:222-228
WHAT WAS RESPONSIBLE FOR THE
CHANGE IN TREAND IN PD GROWTH?
Was it due to:






Medical outcome data?
Burden of therapy?
Physician knowledge?
Expansion in HD capacity?
Lack of PD infrastructure?
Unintended financial constraints?
PD INFRASTRUCTURE ISSUES
Most PD units in the US have < 10 patients
 If this is so, it is hard to justify greater than 2 PD
nurses
As a result:





Hard to grow (remember turnover)
Hard to do a timely start of training (often need to start
now)
Hard to do CQI
Hard to problem solve
Outcomes related to experience
USER-FRIENDLY ENVIRNMENT

For MD

Easy to start patient


Easy to manage patient



CHD vs PD
Protocols
Nurse dietician driven vs MD intensive
For Patient


QOL
Easy care availability
Adjusted relative risk of death by
cumulative number of PD patients treated
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
<100
100-199
200-299
300-399
400-499
>500
Schaubel KI 2000 60:1517-1524
ANZDATA- infection rates
PERITONITIS IN ANZDATA

Peritonitis rates were higher than elsewhere






Australia
New Zealand
Canada
United States
1/20.3 pt months
1/17.0 pt months
1/27.6 pt months
1/32.7 pt months
Death rates (% of episodes) similar
Stated 70% of units no infectious prophylaxis (gent,
mupirocin, anti-fungal)
May be an explanation for why survival advantage for PD
in ANZDATA not as robust as in USRDS
CONSIDER CONSOLIDATION OF
HOME TRAINING UNITS

Robust infrastructure important:






Training (quality of and timing of)
Retraining
Problem solving
Ease of use for patients and MDs
Peritonitis treatment protocols
Allows for eduction
WHAT WAS RESPONSIBLE FOR THE
CHANGE IN TREAND IN PD GROWTH?
Was it due to:

Medical outcome data?


Burden of therapy?




Possibly, but recent DOQI recommendations make care easier
Physician knowledge?


Possibly but not based on recent data
Fellows state they feel that their PD training is subadequate
Expansion in HD capacity?
Lack of PD infrastructure?
Unintended financial constraints?
Inflation Adjusted Devaluation of U.S.
Medicare’s Composite Rate Payment
1974 equivalent
$140
$143.72
Actual CR
$100
$80
1974 dollars adjusted
using US Bureau of
Labor and Statistics
CPI for Medical Care
$60
$40
$20
$15.34
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
1978
1976
$0
1974
Composite Rates
$120
Composite rates from: Rettig & Levinsky, Kidney Failure and the Federal Government, 1991; current CMS published rate
Composite Rate Payment
Equivalent in 1974 Dollars
$1,400
1974 Dollars
Present Value
$1,200
Composite Rate Equivalent
$1,311.36
1974 dollars adjusted
using US Bureau of
Labor and Statistics
CPI for Medical Care
$1,000
$800
$600
$400
$140.00
$200
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
1978
1976
1974
1972
1970
$0
PROVIDERS AND COMPOSITE
RATE


Providers need to be able to make a profit
So as composite rate decreased






Gauze -- 4x4’s to 2x2’s to 1x1’s
Less RNs
Decreased staffing
Reuse
If you focus only on Kt/V – 2 shifts to 3 shifts to 4
shifts a day
Look for another source of “margin”
TOTAL MEDICARE SPENDING
ESRD related Injectables
Period prevalent
dialysis patients..
ESAs: erythropoiesis
stimulating agents.
USRDS 2008: Figure 11.15 (Volume 2)
TOTAL MEDICARE EXPENDATURES
per person per year, by modality
period prevalent ESRD patients. Modalities determined using Model 2 methodology;
patients with Medicare as secondary payor excluded.
USRDS 2008:Figure 11.8 (Volume 2)
GROWING PAYMENT DISPARITY
Yearly Modality Payments (HD vs. PD/patient/yr)
$20,000
$18,910
$18,000
$16,000
U.S. Dollars
$14,000
$12,000
$10,000
$7,216
$8,000
$6,000
$4,000
$2,000
$0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Unadjusted
USRDS Annual Data Report 2007. Data tables k.6 & k.7
Per person per year access costs,
by access type
dialysis patients from
the 1999–2006, ESRD
CPM data with
Medicare as primary
payor & vascular access
data. Intent-to-treat
model. Vascular access
type in use in December
prior to cost years 1999–
2006. Costs include
“pure” inpatient &
outpatient claims &
physician/ supplier
access costs.
USRDS 2008: Figure 11.23 (Volume 2)
CMS ESRD COSTS



About 6% of total Budget, < 1% of recipients
Total amount increasing exponentially
PD costs system less than HD



But, each of us have our hands in different cookie jars
Medicare parts A, B, D
Perverse unintended incentives exist:



Some might be to stimulate home use
Others might favor center HD use
Providers may be influenced by margin potential
2008 Monthly Capitated Payment
HCPCS
Code
2005
2006
2007
2008
1 Visit
G0319
$207
$207
$186
$175
2-3 Visits
G0318
$260
$259
$236
$225
4 Visits
G0317
$312
$311
$287
$274
G0323
$260
$259
$230
$214
Dialysis Services
In- Center Dialysis
Home Dialysis
Full Month
•Calculated From:http://www.cms.hhs.gov/PhysicianFeeSched/01_Overview.asp
•Courtesy of Gary Inglese
The Medicare Modernization Act
(MMA)


It was far more than a Prescription Drug Bill.
It greatly affects the payments to providers
(hospitals, clinics, dialysis units) for injectable
medications


Markedly reduces the “profits” or “margins” from
puchasing a unit of medication
As the composite rate moves towards more bundling,
drugs will be brought into it
Bundling

One payment for numerous services grouped
together


This can get far more complicated



Injectables + dialysis labor and equipment vs.
injectables separate
Monthly, weekly, per treatment schedule?
LDOs and Feds want it
Physicians are +/- because it could include their
fees eventually
TOPICS TO BE COVERED



Outcomes for PD are improving
How can we make them even better
Recommendations
RECOMMENDATIONS






Consider consolidation of Home units
Academia needs to be more involved in PD
FDA needs to reconsider general guidelines for
approval
We need to listen to patients
Should not just think PD VERSUS HD, rather lets
leverage both modalities as clinically appropriate
for the patient
In fact at times, WHY NOT USE BOTH
simultaneously in a patient?
GO TO:
ISPD.org
August 27-19, 2009
QUESTIONS?