title: Early trends from the Study to Evaluate the Prospective Payment System Impact on Small Dialysis Organizations (STEPPS).
abstract: BACKGROUND
  Launched in January 2011, the prospective payment system (PPS) for the US Medicare End-Stage Renal Disease Program bundled payment for services previously reimbursed independently. Small dialysis organizations may be particularly susceptible to the financial implications of the PPS. The ongoing Study to Evaluate the Prospective Payment System Impact on Small Dialysis Organizations (STEPPS) was designed to describe trends in care and outcomes over the period of PPS implementation. This report details early results between October 2010 and June 2011.
  
  
  METHODS
  Prospective observational cohort study of patients from a sample of 51 small dialysis organizations.
  
  
  METHODS
  1,873 adult hemodialysis and peritoneal dialysis patients.
  
  
  RESULTS
  Secular trends in processes of care, anemia, metabolic bone disease management, and red blood cell transfusions.
  
  
  METHODS
  Facility-level data are collected quarterly. Patient characteristics were collected at enrollment and scheduled intervals thereafter. Clinical outcomes are collected on an ongoing basis.
  
  
  RESULTS
  Over time, no significant changes were observed in patient to staff ratios. There was a temporal trend toward greater use of peritoneal dialysis (from 2.4% to 3.6%; P = 0.09). Use of cinacalcet, phosphate binders, and oral vitamin D increased; intravenous (IV) vitamin D use decreased (P for trend for all <0.001). Parathyroid hormone levels increased (from 273 to 324 pg/dL; P < 0.001). Erythropoiesis-stimulating agent doses decreased (P < 0.001 for IV epoetin alfa and IV darbepoetin alfa), particularly high doses. Mean hemoglobin levels decreased (P < 0.001), the percentage of patients with hemoglobin levels <10 g/dL increased (from 12.7% to 16.8%), and transfusion rates increased (from 14.3 to 19.6/100 person-years; P = 0.1). Changes in anemia management were more pronounced for African American patients.
  
  
  CONCLUSIONS
  Limited data were available for the prebundle period. Secular trends may be subject to the ecologic fallacy and are not causal in nature.
  
  
  CONCLUSIONS
  In the period after PPS implementation, IV vitamin D use decreased, use of oral therapies for metabolic bone disease increased, erythropoiesis-stimulating agent use and hemoglobin levels decreased, and transfusion rates increased numerically.
authors: Renal Division and Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA. sbrunelli@partners.org
authors: Steven M
authors: SM
authors: Brunelli
authors: Keri L
authors: KL
authors: Monda
authors: John M
authors: JM
authors: Burkart
authors: Matthew
authors: M
authors: Gitlin
authors: Peter J
authors: PJ
authors: Neumann
authors: Grace S
authors: GS
authors: Park
authors: Margarita
authors: M
authors: Symonian-Silver
authors: Susan
authors: S
authors: Yue
authors: Brian D
authors: BD
authors: Bradbury
authors: Robert J
authors: RJ
authors: Rubin
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000554:Ambulatory Care Facilities / Q000191:economics*; D000740:Anemia / Q000188:drug therapy / Q000191:economics; D050071:Bone Density Conservation Agents / Q000191:economics / Q000627:therapeutic use; D012080:Chronic Kidney Disease-Mineral and Bone Disorder / Q000188:drug therapy / Q000191:economics; D015331:Cohort Studies; D017707:Erythrocyte Transfusion / Q000191:economics / Q000706:statistics & numerical data; D005260:Female; D006397:Hematinics / Q000191:economics / Q000627:therapeutic use; D006437:Hemodialysis, Home / Q000191:economics; D006801:Humans; D007676:Kidney Failure, Chronic / Q000191:economics*; D008297:Male; D006278:Medicare / Q000191:economics*; D008875:Middle Aged; D010530:Peritoneal Dialysis / Q000191:economics / Q000639:trends; D011445:Prospective Payment System / Q000191:economics* / Q000639:trends; D011446:Prospective Studies; D006435:Renal Dialysis / Q000191:economics* / Q000639:trends; D014481:United States; D055815:Young Adult
chemical_list: D050071:Bone Density Conservation Agents; D006397:Hematinics