Abstract
BackgroundA series of policy changes in 2011 altered reimbursement arrangements and guidance on use of erythropoiesis-stimulating agents for end-stage renal disease (ESRD) patients with anaemia in the US. While the policy changes were principally directed at care delivered in an outpatient setting, these had the potential to affect inpatient care also. This study used HCUP-NIS data (2008–2016) to examine trends in recorded anaemia among ESRD hospitalizations and analyse disparities in inpatient outcomes among ethnic groups following policy changes.MethodsThe International Classification of Diseases codes were used to identify ESRD admissions, recorded anaemia due to chronic kidney disease (CKD), and to generate an age-adjusted Deyo-Charlson comorbidity index. Linear splines with a knot placed at the time point of policy changes and multivariable logistic regression were used to examine the likelihood of recorded anaemia, adjusted for a range of socio-demographic and clinical covariates. Difference-in-difference analyses investigated the impact of policies on recorded anaemia. Other outcomes included hospital cost, mortality and place of discharge.ResultsThe percentage of inpatient episodes with recorded anaemia arising from CKD increased from 26.2% in 2008 to 50.0% in 2016. Anaemia was more likely to be recorded as a complication of ESRD among minority ethnic groups and Native American admissions, in particular, (OR 1.20, 95%CI 1.15–1.25) relative to White American admissions; and these disparities widened following changes to reimbursement. Minorities were less likely to die in hospital and to be discharged to another healthcare facility, and (with the exception of Black American admissions) they were more expensive to treat.ConclusionsOur findings provide evidence of an increase in recorded anaemia consistent with a shift of patients from outpatient to inpatient settings in the wake of changes to reimbursement enacted in 2011. In addition, the study highlights the existence of ethnic disparities that widened after the policy initiated reimbursement changes.
Highlights
A series of policy changes in 2011 altered reimbursement arrangements and guidance on use of erythropoiesis-stimulating agents for end-stage renal disease (ESRD) patients with anaemia in the United States (US)
The International Classification of Diseases 9th and 10th Revision (ICD9 and ICD10) codes were used to identify all admissions with a primary diagnosis of ESRD (ICD9 585.6, ICD10 N18.6) and a procedure/diagnosis code referring to any type of renal replacement therapy (RRT, comprising: haemodialysis, peritoneal dialysis and kidney transplantation)
The percentage of inpatient episodes with recorded anaemia arising from chronic kidney disease (CKD) increased from 26.2% in 2008 to 50.0% in 2016
Summary
A series of policy changes in 2011 altered reimbursement arrangements and guidance on use of erythropoiesis-stimulating agents for end-stage renal disease (ESRD) patients with anaemia in the US. In 2011, a series of policy changes adopted in the US combined to change incentives around the use of ESAs. The Medicare ESRD prospective payment system (PPS) implemented in 2011 altered financial incentives by allowing providers to retain payments above Medicare’s reimbursement level while providing dialysis services. In 2011 the ESRD Quality Incentive Payment was implemented [11] This program aimed to raise care quality by imposing a penalty for poor management of dialysis patients including the overuse of ESAs [11]. These three policy changes altered the financial context in which anaemia was managed principally in an outpatient setting. While there is some evidence that the policy changes resulted in shift in transfusions from an outpatient to an inpatient setting [12], their effect on care and outcomes in an inpatient setting more generally have not to our knowledge been examined
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