Comparative changes in treatment practices and clinical outcomes following implementation of a prospective payment system: the STEPPS study.
BACKGROUND
The aim of the US dialysis Prospective Payment System bundle, launched in January 2011, was reduction and more accurate prediction of costs of services, whilst maintaining or improving patient care. Dialysis facilities could either adopt the bundle completely (100%) in the first year of launch, or phase-in (25%) over four years. Differences in practice patterns and patient outcomes were hypothesized to occur in facilities that phased-in 25% compared to those that did not.


METHODS
Data are from STEPPS, a study of 51 small dialysis organization facilities designed to describe trends in dialytic treatment before and after bundle implementation. Baseline was defined as October-December 2010; follow-up as January-December 2011. Facility- and patient-level data were collected at enrollment and regularly thereafter. Cox proportional hazards and linear multi-level models were used to estimate the effect of opting-in 25% (vs. 100%) on practice patterns and clinical outcomes.


RESULTS
12 facilities (patient n = 346) opted-in 25% and 37 facilities (patient n = 1296) opted-in 100% to the dialysis bundle. At baseline, patients at 25% facilities were primarily covered by Medicare, were more likely to be black, and were receiving higher monthly epoetin alfa (EPO) doses. Throughout 2011, patients in 100% facilities received lower monthly EPO doses, and had lower mean hemoglobin concentrations; hospitalization and mortality rates were numerically lower in 25% facilities but not statistically different.


CONCLUSIONS
The economic pressure for dialysis providers to work within an expanded composite rate bundle whilst maintaining patient care may be a driver of practice indicator outcomes. Additional investigations are warranted to more precisely estimate clinical outcomes in patients attending facilities enrolling into the bundle 100% relative to the previous fee-for-service framework.
Center for Observational Research, Amgen, Inc, One Amgen Center Drive MS 24-2-A, Thousand Oaks, CA, 91320-1799, USA. kmonda@amgen.com.
Keri L
KL
Monda
Center for Observational Research, Amgen, Inc, One Amgen Center Drive MS 24-2-A, Thousand Oaks, CA, 91320-1799, USA. njoseph@amgen.com.
Parveen Nedra
PN
Joseph
Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA. pneumann@tuftsmedicalcenter.org.
Peter J
PJ
Neumann
Center for Observational Research, Amgen, Inc, One Amgen Center Drive MS 24-2-A, Thousand Oaks, CA, 91320-1799, USA. bradbury@amgen.com.
Brian D
BD
Bradbury
Division of Nephrology and Hypertension, Georgetown University School of Medicine, Washington, DC, USA. rjrmd@comcast.net.
Robert J
RJ
Rubin
D000328:Adult; D000368:Aged; D000554:Ambulatory Care Facilities / Q000191:economics*; D000740:Anemia / Q000150:complications / Q000188:drug therapy*; D000068817:Epoetin Alfa / Q000627:therapeutic use*; D005260:Female; D006397:Hematinics / Q000627:therapeutic use*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications / Q000401:mortality / Q000628:therapy*; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010818:Practice Patterns, Physicians'; D016016:Proportional Hazards Models; D011445:Prospective Payment System; D019984:Quality Indicators, Health Care; D006435:Renal Dialysis / Q000191:economics* / Q000379:methods; D014481:United States
D006397:Hematinics; D000068817:Epoetin Alfa