Medicaid Coverage and Nephrology Care Influence Patient Mortality among United States Dialysis Facilities Public
Hao, Hua (2013)
Published
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
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