Medicare Bundled Payment Policy on Anemia Care, Major Adverse Cardiovascular Events, and Mortality among Adults Undergoing Hemodialysis

Park, Haesuk; Desai, Raj; Smith, Steven M.; Hincapie-Castillo, Juan M.; Henry, Linda; Goodin, Amie; Gopal, Saraswathi; Pepine, Carl J.; Mohandas, Rajesh

doi:10.2215/cjn.14361121

Cited by 7 publications

(10 citation statements)

References 35 publications

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“…Hemoglobin concentration is an independent contributing factor for the development of HF and HFpEF in our analysis, with a negative sign. This is in line with literature data that anemia in CKD patients and those treated with dialysis is a strong predictor of HF [1,2,25].…”

Section: Discussionsupporting

confidence: 92%

Chronic heart failure phenotypes in prevalent patients treated with hemodialysis: A single-center experience

Dobricic¹,

Pakic²,

Arsenović³

et al. 2022

Srp Arh Celok Lek

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Introduction/Objective. Heart failure (HF) is the main cause of morbidity and mortality of hemodialysis (HD) patients. The aim of this cross-sectional, single center, study was to examine: 1. frequency and characteristics of HF phenotypes in prevalent HD patients, 2. association of HF with traditional and non-traditional risk factors for cardiovascular diseases. Methods. We included all 96 maintenance HD patients from Special Hospital for Internal Diseases, Lazarevac, Serbia, and determined the prevalence of HF with preserved ejection fraction- HFpEF (per the 2016 criteria of the European Society of Cardiology) and HF with reduced and moderately reduced EF-HFrEF +HFmrEF- together in a group HFrEF (EF < 50%) using standardized post-HD transthoracic echocardiography. Clinical, routine laboratory and volume status parameters (by bioimpedance spectroscopy) was assessed. Results. 63 /96 examined patients (65.6%) had HF, among them 42 had HFpEF (66.7%), and 21 had HFrEF (33.3%). HFrEF was more common in older males, with diabetic nephropathy as underlying kidney disease (DN), with a longer dialysis vintage and in those with a previous history of ischemic heart disease. HFpEF was more common in males, with lower HD quality (kT/V) and higher pre-dialytic systolic blood pressure. In multivariable regression analysis, HFrEF was associated with DN, hypervolemia (positively) and triglyceride (negatively), while HFpEF was associated negatively with hemoglobin, iron and triglyceride. Conclusion. In order to control patients on maintenance HD with HF, in addition to appropriate drug therapy, it is advice to control of volemia and maintaining triglyceride, hemoglobin and iron concentration approximately within normal limits.

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Section: Discussionsupporting

confidence: 92%

Chronic heart failure phenotypes in prevalent patients treated with hemodialysis: A single-center experience

Dobricic¹,

Pakic²,

Arsenović³

et al. 2022

Srp Arh Celok Lek

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“…The ETC model may still be effective over time because dialysis facilities are predominantly for profit (89% of facilities) and have been highly responsive to previous payment policy changes. 14 Other ESKD-focused policies, including the ESRD Prospective Payment System and specialty-oriented accountable care organizations (the Comprehensive ESRD Care Model) have shown promise in improving quality and constraining costs for this population. 15 The ETC model also incorporates innovative policy elements, such as an equity incentive and stratified benchmarks, that are designed to reduce disparities between patients with lower incomes (those dually eligible for Medicaid or who received the low-income subsidy) and those with higher incomes.…”

mentioning

confidence: 99%

Early Findings From Medicare’s End-Stage Renal Disease Treatment Choices Model

2022

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Patients with end-stage kidney disease (ESKD) incur substantial costs for the Medicare program while experiencing high rates of adverse outcomes. 1 Substantial racial, ethnic, and socioeconomic disparities also persist among patients with ESKD. 2 Consequently, improving ESKD care has been a key focus for the US Centers for Medicare & Medicaid Services. A recent major initiative focuses on increasing home dialysis (peritoneal dialysis and home hemodialysis), kidney transplant waitlisting, and living donor transplant rates through Medicare's End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model. 3 In this issue of JAMA Health Forum, Ji and colleagues 4 report what is to our knowledge the first peer-reviewed evaluation of a key outcome in the ETC model. Their study found that financial incentives in the ETC model's first year (2021) had no significant effect on the percentage of patients initiating treatment with home dialysis. Results were consistent across patient characteristics, dialysis facility size, and facility profit status.The ETC model and this evaluative study are important for several reasons. First, the ETC model is one of the largest health care policy experiments in US history and randomizes 30% of hospital referral regions to receive financial incentives. Its randomized design with mandatory participation overcomes issues with selection bias that are typically seen with voluntary models. Second, the policy design tests a meaningful shift in financial incentives through pay-for-performance elements.The ETC model focuses on a parsimonious set of performance measures and uses sizeable payment incentives to motivate changes in practice patterns (up to 8% bonus or −10% penalty in the final year). Third, the ETC model has taken a novel step forward by adding an equity incentive in 2022 to reduce socioeconomic disparities in home dialysis and transplant.Ji and colleagues 4 have provided timely, actionable findings to inform policy implementation of the ETC model. Their evaluation is exemplary in its use of a prespecified analysis plan, power calculations to inform detectable effect sizes, and rigorous sensitivity analyses. Their finding that home dialysis use increased in ETC and non-ETC regions (from 16.5% in 2018 to 20.6% in 2021) is promising because home dialysis is associated with clinical benefits compared with in-center hemodialysis, including improved quality of life and better preservation of residual kidney function. 5 Home dialysis use has been increasing since 2008, so interrupted time series could examine if the increases reported by Ji and colleagues 4 represent a departure from prior trends. 1 This study raises several opportunities for further inquiry. First, rates of home dialysis use in the study sample (patients with incident ESKD 66 years or older) are higher than estimates from the US Renal Data System (16.5% vs 9.1% in 2018) and analyses of prevalent patients. 1,6 Differences in inclusion criteria and/or outcome definitions may explain these discrepancies and will be important...

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“…Lastly, it was cited that after ESA usage was decreased, patients with anemia “were associated with lower risks of major adverse cardiovascular event, stroke, mortality, and heart failure but higher risk of acute myocardial infarction among adults receiving hemodialysis” (1). I must ask, has the pendulum swung too far the other way?…”

mentioning

confidence: 99%

“…I appreciate the opportunity to comment on the article appearing in this issue of CJASN , titled “Medicare Bundled Payment Policy on Anemia Care, Major Adverse Cardiovascular Events, and Mortality among Adults Undergoing Hemodialysis,” by Park et al (1). I have lived with CKD for 24 years.…”

mentioning

confidence: 99%

“…This started a trend of using different ways to treat anemia that were less costly. When the number of iron infusions increased, “Use of intravenous iron supplementation was relatively stable, but after January 2012, there was an immediate increase in the prevalence of iron use” (1). In my experience, bowel impactions are common in patients living on dialysis.…”

mentioning

confidence: 99%

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