Medicaid Coverage and Nephrology Care Influence Patient Mortality among United States Dialysis Facilities Open Access

Abstract

Background: Pre-ESRD nephrology care is important for better clinical outcomes for patients with end stage renal disease (ESRD). Timely receipt of nephrologist care is associated with slower chronic kidney disease (CKD) progression and lower rates of adverse outcomes. Prior studies suggest that patient socioeconomic status may be an indicator for late nephrologist referral. The aim of this study was to determine the association between pre-ESRD nephrology care and standardized mortality ratio among dialysis facilities in the US, and to determine whether this association varied by Medicaid health insurance coverage.

Methods: A total of 5,387 dialysis facilities were identified from the Dialysis Facility Report data from 2007-2010, which presented detailed data from the ESRD Medical Evidence Form (FORM CMS-2728) across 18 dialysis facility networks (56 states and territories) in the U.S. Receipt of pre-ESRD nephrology care was based on the CMS 2728 Medical Evidence Form. Standardized mortality ratio (SMR) was calculated as the number of observed deaths within a dialysis facility over the number of expected deaths within a facility. A marginal mixed generalized estimating equation model assuming exchangeable covariance structure was used to estimate the association between pre-ESRD nephrology care and facility SMR as well as effect modification of Medicaid coverage.

Results: The percentage of patients who received pre-ESRD nephrology care within a facility was significantly associated with facility-level SMR. In particular, for a ten percent increase in pre-ESRD nephrology care, facility SMR decreased 1.30% ( 95% CI, 0.90%-1.61%). Compared to facilities whose proportion of patients received Medicaid coverage (MC) greater than the third quartile, facilities whose MC lower than the first quartile experienced a significant 1.10% (95% CI, 0.10%-2.10%) increase in rate of change between pre-ESRD nephrology care and facility SMR.

Conclusion: As the percentage of patients who received pre-ESRD nephrology care within a facility increased, the facility-level SMR decreased. This association was modified by patient Medicaid coverage, where a decreased proportion of patients who received Medicaid Coverage resulted in a steeper rate of change. These results suggested that targeted quality improvement interventions to improve access to pre-ESRD nephrology care could reduce mortality among ESRD patients in dialysis facilities.

Table of Contents

CHAPTER 1-LITERATURE REVIEW AND INTRODUCTION.. 11

Introduction. 11

Chronic Kidney Disease 11

Definition. 11

Morbidity and Mortality 11

Progression and Stage of CKD 12

Predictors of CKF. 12

Economic Burden of Kidney Disease 14

Summary. 15

Pre-ESRD Nephrology Care 15

Definition. 15

Pre-ESRD Nephrology Care and Nephrologist Referral 15

Significance. 15

Prevalence. 16

Previous Relevant Study Methodology and Result for Evaluating the Association between CKD mortality or survival and Pre-ESRD Nephrology Care or Early Nephrology Referral 17

Summary. 21

Medicaid Coverage 21

Definition. 21

Medicaid Coverage Linked to Socioeconomic Status. 21

Medicaid Coverage Linked Pre-ESRD Nephrology Care or Early Referral 22

Summary. 23

Statement of Research Objectives 23

CHAPTER 2: MANUSCRIPT 25

TITLE. 25

ABSTRACT. 25

INTRODUCTION.. 26

METHODS. 28

Study Population. 28

Pre-ESRD Nephrology Care Coverage 29

Standardized Mortality Ratio (SMR) 29

Medicaid Coverage 29

Other Facility and Clinical Characteristics 29

Statistical Analysis 30

RESULTS. 32

Study Population. 32

Longitudinal Change in Standardized Mortality Ratio, pre-ESRD Nephrologist Care and Relevant Covariates 33

Association between Potential Covariates and Pre-ESRD Nephrologist Care and Standardized Mortality Ratio 34

Association between Pre-ESRD Nephrology Care and Standardized Mortality Ratio. 34

Association between Pre-ESRD Nephrology Care and Standardized Mortality Ratio Modified by Percentage of Patients Receiving Medicaid Coverage Only. 35

Sensitivity Analysis 36

DISCUSSION.. 37

REFERENCES 41

TABLE 47

Table 1. Baseline year characteristics of the study population 47

Table1. Baseline year characteristics of the study population(Continued)48

Table 2. Longitudinal Change in Standardized Mortality Ratio, pre-ESRD Nephrologist Care and Relevant Covariates. 48

Table 3. Association between Potential Covariates and Pre-ESRD Nephrologist Care and Standardized Mortality Ratio 50

Table 4. Association between Pre-ESRD Nephrologist Care and Log-transformed Standardized Mortality Ratio 50

Table 5. Stratified Patient Medicaid Coverage (MC) on Association between Pre-ESRD Nephrologist Care and Standardized Mortality Ratio (SMR).51

CHAPTER 3: SUMMARY, PUBLIC HEALTH IMPLICATION, POSSIBLE FUTURE DIRECTION .. 51

SUMMARY .. 51

PUBLICH HEALTH IMPLICATION .. 52

POSSIBLE FUTURE DIRECTION .. 52

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Statistics Health Sciences, Epidemiology
Keyword	longitudinal study medicaid coverage dialysis nephrology care marginal model
Committee Chair / Thesis Advisor	Patzer, Rachel Elizabeth, Emory University
Committee Members	Chang, Howard, Emory University
Partnering Agencies	Emory University schools, faculty or affiliated programs

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