Study shows cost, outcomes are similar for peritoneal vs in-center hemodialysis
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Despite fewer comorbidities and access to pre-dialysis care, patients on peritoneal dialysis do not have lower mortality, hospitalizations or cost of care compared with those on in-center hemodialysis, a recently published study shows.
Eugene Lin, MD, MS, of the division of nephrology in the department of medicine at Keck School of Medicine, and colleagues said the review is timely as CMS develops payment models that incentivize dialysis providers to encourage patients to choose home dialysis.
“We found no evidence that increasing PD use for patients with incident ESKD would offer reductions in mortality, hospitalizations, or cost,” the authors said. “Policy makers eager to promote home dialysis should temper expectations of improved outcomes and reduced spending.”
The researchers used an instrumental variable (IV) analysis to reach their conclusions.
“The value of the IV analysis is that we can leverage the power of randomization without needing to conduct a randomized trial,” Lin told Healio Nephrology. “The policy acts as a randomizer by encouraging patients starting later in the month to do PD. Previous studies didn’t do this and have a statistical bias, which is why they have tended to show better outcomes and lower costs with PD.”
The researchers looked at uninsured patients in the first 3 months of dialysis; Medicare coverage of patients diagnosed with end-stage kidney disease does not begin until the fourth month of care if a patient is dialyzed in-center. For those who choose a home modality, however, Medicare begins payment to the provider on the first day of dialysis.
In addition, “Starting [PD] later in a calendar month increases pre-dialysis coverage that is essential for PD catheter placements,” the authors said, “The policy encourages PD incrementally when ESKD develops later in the month.”
Study group
From the U.S. Renal Data System, the researchers identified 58,539 uninsured adults starting dialysis between June 1, 2005 and Dec. 31, 2014. They used Medicare Part A and B claims to obtain total Medicare spending, hospitalizations, outpatient dialysis services and physician dialysis visits.
“Our main outcomes were 12-month mortality, number of hospitalizations per patient during dialysis months 7 to 12 ... and Medicare spending per patient during dialysis months 7 to 12,” they said.
Of the patients in the study group, 8% started with PD. “Compared with patients starting with HD, patients starting with PD were younger; were more likely female, white, and employed; had fewer comorbidities; and had higher serum albumin and hemoglobin,” the authors wrote. “They were more likely to receive pre-dialysis nephrology care and dialyze at for-profit, free-standing, and urban facilities with large PD populations.”
Results
The study findings showed patients starting with PD had significantly higher survival at 1 year vs. patients on in-center hemodialysis (96% vs. 92%) and fewer hospitalizations during months 7 to 12 (0.61 vs. 0.69) compared with patients on hemodialysis, but higher logarithm transformed spending during months 7 to 12 ($15,917 for patients on PD vs. $10,622 for patients on hemodialysis). PD was less expensive than HD during months 7 to 12 ($27,386 vs. $30,875).
“The benefit of log costs is that it removes extreme outliers, a commonly employed technique in economics,” Lin told Healio Nephrology. “However, we also conducted the analysis using non-log[arithm]-transformed spending, which showed the same result.”
When adjusted for confounders, the "traditional" analysis showed decreased mortality and increased spending for PD vs. HD. However, “after accounting for selection bias, we found that initiating PD (rather than HD) did not result in statistically significant differences in mortality, hospitalizations or Medicare spending in uninsured adults with ESKD,” the authors concluded. “Unlike other observational studies, ours used an ostensibly random event, the day of dialysis start, to mitigate bias from ‘unobserved’ characteristics. We found mortality and cost differences when using traditional observational methods that dissipated with IV regression.”
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