Kidney failure care is disproportionately costly, in part due to underutilization of treatments and services associated with improved health outcomes and lower costs of care. The objective of this dissertation was to investigate factors that may contribute to inequities in access to preferred treatments (early kidney transplantation, peritoneal dialysis, home hemodialysis) and services (advance care planning) among Medicare beneficiaries with kidney failure. The first aim assesses nephrologist participation in Medicare’s Comprehensive End-Stage Renal Disease Care (CEC) Initiative—a voluntary, kidney failure-specific alternative payment model intended to improve the value of care among beneficiaries receiving maintenance dialysis—to determine if the CEC was meaningfully available to socially vulnerable populations. By analyzing provider-level data for all US nephrologists, I found that nephrologists practicing in communities with more financial resources and higher demand for dialysis care were more likely to participate in the CEC Initiative, suggesting that patients receiving dialysis in low-income and rural communities were less likely to have access to high-value nephrology care. The second aim used data from the United States Renal Data System, a national database for kidney failure patients, to estimate the causal effect of CEC Initiative participation on patients’ use of preferred kidney failure treatments. This study found that patients treated by CEC participating nephrologists were less likely to receive pre-emptive or early kidney transplant compared to patients treated by non-participants, though use of home dialysis was not affected. Finally, aim 3 provides the first characterization of advance care planning use among patients with kidney failure and the first evidence of racial and ethnic disparities in use of advance care planning in this population. Together, the results from this dissertation provide insight into the relationships among kidney failure patients’ race/ethnicity, community socioeconomic status, and access to high-value care, providing novel targets for policy makers seeking to mitigate disparities in access to preferred treatments and patient-centered services in kidney failure care.
Table of Contents
Paper 1: Characteristics of nephrologists participating in Medicare’s Comprehensive ESRD Care (CEC) Initiative
Paper 2: Impact of Medicare’s Comprehensive ESRD Care Initiative on Nephrologists' Treatment of Patients with New-Onset End-Stage Renal Disease
Paper 3: Use of Advance Care Planning among Medicare beneficiaries with kidney failure
About this Dissertation
|Committee Chair / Thesis Advisor|
|File download under embargo until 26 May 2028||2022-03-31 18:59:51 -0400||File download under embargo until 26 May 2028|