BACKGROUND & AIMS: :Research was undertaken to determine the effects of hospital ownership, location, and Medicare's prospective payment system (PPS) on inpatient uncompensated care. A nonequivalent group design was used with repeated measures of uncompensated care (UNCC) on 137 system hospitals taken pre- and post-PPS. Investor-owned system hospitals demonstrated the largest increase in UNCC (37 percent) under the PPS. Results suggest that not-for-profit and investor-owned system hospitals are becoming more similar in levels of uncompensated care provided and that the PPS has had a negative effect on rural hospital profitability.

背景与目标： : 进行了研究，以确定医院所有权，位置和Medicare的预期支付系统 (PPS) 对住院患者无偿护理的影响。在PPS前后采取的137系统医院中，使用了非等效的组设计，并重复进行了无补偿护理 (UNCC)。投资者拥有的系统医院在PPS下显示出最大的UNCC (37%) 增长。结果表明，非营利性和投资者拥有的系统医院在提供的无偿护理水平上变得越来越相似，PPS对农村医院的盈利能力产生了负面影响。

BACKGROUND & AIMS: PURPOSE:Efforts to curb the rising costs of cancer care while improving quality include alternative payment models (APMs), which offer incentives to reduce avoidable spending and provide high-quality and cost-efficient care. The impact of proposed APMs has not been quantified in real-world practice. In this study, we evaluated ASCO's Patient-Centered Oncology Payment (PCOP) model in existing fee-for-service (FFS) Medicare beneficiaries to understand the magnitude of potential cost savings. MATERIALS AND METHODS:SEER-Medicare data were used to identify women with advanced ovarian cancer diagnosed between 2000 and 2012 who either (1) underwent primary debulking surgery followed by chemotherapy or (2) received neoadjuvant chemotherapy followed by surgery. Medicare payments in each cohort were used to compare FFS and PCOP and to estimate the potential for cost savings across health care services received, including outpatient emergency department visits, hospitalizations, and imaging. RESULTS:Three thousand seven hundred seventy-seven primary debulking surgery and 866 neoadjuvant chemotherapy patients were included in the study, with mean total costs of $75,433 and $95,138 in 2016 US$, respectively Most costs were related to chemotherapy or hospitalization. Additional PCOP-related payments would be offset if hospitalizations could be reduced by 11.6% or imaging claims by 88%. CONCLUSION:APMs have the potential to reduce costs of current FFS reimbursement via either a large reduction in imaging or a modest reduction in hospitalizations during treatment of ovarian cancer. PCOP is a reasonable payment structure for oncologists if the additional payments can provide the necessary resources to invest in improved coordination of care.

背景与目标：

BACKGROUND & AIMS: :We examined the effects of Resource-based Relative Value Scale (RBRVS)- and physician diagnosis-related groups (MDDRG)-based payment for anesthesiology services related to surgery by simulating these physician payment reform options. We merged Medicare Part A (hospital) and Part B (anesthesiology) payment data for 7,770 patients for the MDDRG analysis and examined 10,431 surgical procedures for the RBRVS analysis within 27 diagnosis-related groups (DRGs) during the second half of 1986 in 16 hospitals representing different geographic regions, bed size, and teaching status. Assuming budget neutrality (i.e., constant total expenditure for anesthesiology services) and using the proposed methodologies, we simulated RBRVS and MDDRG payments and compared them to current payments for anesthesiology services. Individual surgical procedures demonstrated a two- to more than four-fold variation in duration, accompanied by a similar variation in anesthesiology payments. Within DRGs, there was a three- to ten-fold variation in duration, and a two- to seven-fold variation in anesthesiology payments. Anesthesiology time was highly correlated with surgical time (r = 0.86-0.96). Compared to the current system, RBRVS and MDDRG systems were associated with systematic variations in payments, such that on average, on each case, anesthesiologists practicing in rural and nonteaching hospitals would gain, whereas those in urban or suburban and teaching facilities would lose. After adjusting for complexity of procedure, the distribution of payment gains and losses was a function of duration of surgery, which is not influenced by the anethesiologist. Longer cases of a given surgical procedure result in payment decreases. The results document the importance of retaining a time factor in the payment methodology for anesthesiology services to maintain equitable payment across practice settings--an objective of physician payment reform.

背景与目标： : 我们通过模拟这些医生支付改革方案，研究了基于资源的相对价值量表 (RBRVS) 和基于医生诊断相关组 (MDDRG) 的支付对与手术相关的麻醉学服务的影响。我们合并了用于MDDRG分析的7,770名患者的Medicare A部分 (医院) 和B部分 (麻醉学) 支付数据，并在下半年1986年在代表不同地理区域的16家医院的27个诊断相关组 (drg) 中检查了RBRVS分析的10,431手术程序，和教学状况。假设预算中立 (即麻醉学服务的总支出恒定) 并使用建议的方法，我们模拟了rbrv和MDDRG付款，并将其与麻醉学服务的当前付款进行了比较。单个外科手术的持续时间显示出两到四倍以上的变化，伴随着麻醉学付款的类似变化。在DRGs中，持续时间变化为3到10倍，麻醉学付款变化为2到7倍。麻醉时间与手术时间高度相关 (r = 0.86-0.96)。与目前的系统相比，RBRVS和MDDRG系统与支付的系统性差异相关，因此平均而言，在每种情况下，在农村和非教学医院执业的麻醉师都会受益，而在城市或郊区和教学设施的麻醉师则会流失。在调整了手术的复杂性之后，付款损益的分布是手术持续时间的函数，不受外科医生的影响。给定手术程序的较长情况会导致付款减少。结果表明，在麻醉学服务的支付方法中保留时间因素以维持整个执业环境的公平支付的重要性-这是医生支付改革的目标。

BACKGROUND & AIMS: BACKGROUND:Much attention has been paid to improving the care of patients with cardiovascular disease by focusing attention on delivery system redesign and payment reforms that encompass the healthcare spectrum, from an acute episode to maintenance of care. However, 1 area of cardiovascular disease care that has received little attention in the advancement of quality is cardiac rehabilitation (CR), a comprehensive secondary prevention program that is significantly underused despite evidence-based guidelines that recommending its use. PURPOSE:The purpose of this article was to analyze the applicability of 2 payment and reimbursement models-pay-for-performance and bundled payments for episodes of care--that can promote the use of CR. CONCLUSIONS:We conclude that a payment model combining elements of both pay-for-performance and episodes of care would increase the use of CR, which would both improve quality and increase efficiency in cardiac care. Specific elements would need to be clearly defined, however, including: (a) how an episode is defined, (b) how to hold providers accountable for the care they provider, (c) how to encourage participation among CR providers, and (d) how to determine an equitable distribution of payment. CLINICAL IMPLICATIONS:Demonstrations testing new payment models must be implemented to generate empirical evidence that a melded pay-for-performance and episode-based care payment model will improve quality and efficiency.

背景与目标：

BACKGROUND & AIMS: OBJECTIVE:To examine changes in postacute care (PAC) use during the initial Medicare payment reforms enacted by the Balanced Budget Act of 1997. DATA SOURCES:We used claims data from the 5 percent Medicare beneficiary sample in 1996, 1998, and 2000. Linked data from the Denominator file, Provider of Service file, and Area Resource File provided additional patient, hospital, and market-area characteristics. STUDY DESIGN:Six disease groups with high PAC use were selected for analysis. We used multinomial logit regression to examine how PAC use differed by year of service, controlling for patient, hospital, and market-area characteristics. PRINCIPAL FINDINGS:There were major changes in PAC use, and a portion of services shifted to settings where reimbursement remained cost-based. During the first reform, the home health agency interim payment system, home health use decreased consistently across disease groups. This decrease was accompanied by increased use in skilled nursing facilities (SNFs). Following the implementation of the prospective payment system for SNFs, the use of inpatient rehabilitation facilities increased. CONCLUSIONS:The shift in usage among settings occurred in two stages that corresponded to the timing of payment reforms for home health agencies and SNFs. Evidence strongly suggests the substitutability between PAC settings. Financial incentives, in addition to clinical needs and individual preferences, play a major role in PAC use.

背景与目标：

BACKGROUND & AIMS: :The Tax Cuts and Jobs Act (TCJA) eliminated the ACA's "shared responsibility payment," which penalized those who failed to comply with the requirement to purchase health insurance. In this article the authors explain efforts in several states to respond to this change by adopting individual health insurance mandates at the state level. Although there are good reasons to think that states may be reluctant to consider establishing their own mandates, New Jersey, the District of Columbia, and Vermont quickly joined Massachusetts in establishing such measures in 2018. In 2019 California and Rhode Island enacted state-level mandates. Four other states-Maryland, Connecticut, Hawaii, and Washington-formally considered mandates but have not enacted them. The authors compare the policy debates among these states and one other state, New York, which has not seen a legislative proposal for a mandate despite its strong support for the ACA. Their analysis explores the dynamics within the US federal system when a key component of a complex and politically salient national initiative is eliminated and states are left with many policy, political, and administrative questions of what to do next.

背景与目标： : 《减税和就业法案》 (TCJA) 取消了ACA的 “分担责任付款”，该付款对那些不遵守购买健康保险要求的人进行了处罚。在本文中，作者解释了几个州通过在州一级采用个人健康保险授权来应对这一变化的努力。尽管有充分的理由认为各州可能不愿考虑建立自己的任务，但新泽西州，哥伦比亚特区和佛蒙特州迅速加入马萨诸塞州，2018年制定了此类措施。2019年，加利福尼亚州和罗德岛州颁布了州级授权。其他四个州-马里兰州，康涅狄格州，夏威夷州和华盛顿州-正式考虑了授权，但尚未颁布。作者比较了这些州和另一个州 (纽约州) 之间的政策辩论，尽管纽约州大力支持ACA，但纽约州尚未看到授权的立法提案。他们的分析探讨了当复杂且具有政治意义的国家倡议的关键组成部分被消除时，美国联邦系统内的动态，各州面临着下一步要做的许多政策，政治和行政问题。

BACKGROUND & AIMS: BACKGROUND:Acute 24-h detoxification services (detox) are necessary but insufficient for many individuals working towards long-term recovery from opiate, alcohol or other drug addiction. Longer engagement in substance use disorder (SUD) treatment can lead to better health outcomes and reductions in overall healthcare costs. Connecting individuals with post-detox SUD treatment and supportive services is a vital next step. Toward this end, the Massachusetts Medicaid program reimburses Community Support Program staff (CSPs) to facilitate these connections. CSP support services are typically paid on a units-of-service basis. As part of a larger study testing health care innovations, one large Medicaid insurer developed a new cadre of workers, called Recovery Support Navigators (RSNs). RSNs performed similar tasks to CSPs but received more extensive training and coaching and were paid an experimental case rate (a flat negotiated reimbursement). This sub-study evaluates the feasibility and impact of case rate payments for RSN services as compared to CSP services paid fee-for-service. METHODS:We analyzed claims data and RSN service data for a segment of the Massachusetts Medicaid population who had more than one detox admission in the last year and also engaged in post-discharge CSP or RSN services. Qualitative data from key informant interviews and Learning Collaboratives with CSPs and RSNs supplemented the findings. RESULTS:Clients receiving RSN services under the case rate utilized the service significantly longer than clients receiving CSP services under unit-based billing. This resulted in a lower average cost per member per month for RSN clients. However, when calculating total SUD treatment costs per member, RSN client costs were 50% higher than CSP client costs. Provider organizations employing RSNs successfully implemented case rate billing. Benefits included allowing time for outreach efforts and training and coaching, activities not paid under the unit-based system. Yet, RSNs identified staffing and larger systems level challenges to consider when using a case rate payment model. CONCLUSIONS:Addiction is a chronic disease that requires long-term investments. Case rate billing offers a promising option for payers and providers as it promotes continued engagement with service providers. To fully realize the benefits of case rate billing, however, larger systems level changes are needed.

背景与目标：

BACKGROUND & AIMS: :We provide an analysis of the effect of physician payment methods on their hospital patients' length of stay and risk of readmission. To do so, we exploit a major reform implemented in Quebec (Canada) in 1999. The Quebec Government introduced an optional mixed compensation (MC) scheme for specialist physicians working in hospital. This scheme combines a fixed per diem with a reduced fee for services provided, as an alternative to the traditional fee-for-service system. We develop a model of a physician's decision to choose the MC scheme. We show that a physician who adopts this system will have incentives to increase his time per clinical service provided. We demonstrate that as long as this effect does not improve his patients' health by more than a critical level, they will stay more days in hospital over the period. At the empirical level, we estimate a model of transition between spells in and out of hospital analog to a difference-in-differences approach. We find that the hospital length of stay of patients treated in departments that opted for the MC system increased on average by 4.2% (0.28 days). However, the risk of readmission to the same department with the same diagnosis does not appear to be overall affected by the reform.

背景与目标： : 我们分析了医生付款方式对其住院患者的住院时间和再入院风险的影响。为此，我们利用在魁北克 (加拿大) 1999年实施的一项重大改革。魁北克政府为在医院工作的专科医生引入了可选的混合补偿 (MC) 计划。该计划将固定的每日津贴与减少的服务费用相结合，以替代传统的按服务收费系统。我们开发了一个医生决定选择MC方案的模型。我们证明，采用该系统的医生将有动力增加其每次提供的临床服务的时间。我们证明，只要这种效果不会使患者的健康状况改善超过临界水平，他们将在此期间住院更多的时间。在经验层面上，我们估计了一个模型，该模型是在医院内和外的法术之间转换为差异差异方法的模型。我们发现，在选择MC系统的部门接受治疗的患者的住院时间平均增加了4.2% (0.28天)。但是，以相同的诊断再次进入同一部门的风险似乎并未受到改革的总体影响。

BACKGROUND & AIMS: BACKGROUND:Tanzania is one of many low income countries committed to universal health coverage and Sustainable Development Goals. Despite these bold goals, there is growing concern that the country could be off-track in meeting these goals. This prompted the Government of Tanzania to look for ways to improve health outcomes in these goals and this led to the introduction of Payment for Performance (P4P) in the health sector. Since the inception of P4P in Tanzania a number of impact, cost-effective and process evaluations have been published with less attention being paid to the experiences of care in this context of P4P, which we argue is important for policy agenda setting. This study therefore explores these experiences from the perspectives of health workers, service users and community health governing committee members. METHODS:A qualitative study design was used to elicit experiences of health workers, health service users and health governing committee members in Rufiji district of the Pwani region in Tanzania. The Payment for Performance pilot was introduced in Pwani region in 2011 and data presented in this article is based on this pilot. A total of 31 in-depth interviews with health workers and 9 focus group discussions with health service users and health governing committee members were conducted. Collected data was analysed through qualitative content analysis. RESULTS:Study informants reported positive experiences with Payment for Performance and highlighted its potential in improving the availability, accessibility, acceptability and quality of care (AAAQ). However, the study found that persistent barriers for achieving AAAQ still exist in the health system of Tanzania and these contribute to negative experiences of care in the context of P4P. CONCLUSION:Our findings suggest that there are a number of positive aspects of care that can be improved by Payment for Performance. However its targeted nature on specific services means that these improvements cannot be generalized at health facility level. Additionally, health workers can go as far as they can in improving health services but some factors that act as barriers as demonstrated in this study are out of their control even in the context of Payment for Performance. In this regard there is need to exercise caution when implementing such initiatives, despite seemingly positive targeted outcomes.

背景与目标：

BACKGROUND & AIMS: UNLABELLED:Analysis of the resource-based relative value scale (RBRVS) for physician payment indicates that in 1996, hourly reimbursement rates will be unrelated to the intensity of work and income will be unrelated to hours worked. A "consensus method" of payment is proposed as an alternative to the RBRVS.

METHOD:As with the method of the RBRVS study, a pilot survey asked a specialty-representative cohort of physicians to assign dimensionless numbers to the relative value of work in 15 specialties using the Hsiao et al. definition of work intensity as "time modified by, a) mental effort, b) clinical judgment, c) technical skill, and d) physical effort under stress." The consensus method is similar to that of the Hsaio method, except there is no mathematical transformation of the raw data to establish specialty work values once the data are collected. A comparative analysis was then made of work hours, reimbursement rates, and annual income with 1) the customary prevailing and reasonable system (CPR, pre-1992), 2) the RBRVS system (1996), and 3) the proposed consensus system.

RESULTS:The RBRVS intends that physicians be reimbursed on the basis of time and intensity of work. Neither the CPR nor the RBRVS systems accomplish this objective when the data and computational methods of the Physician Payment Review Commission are used with independently determined work intensity to compute hourly reimbursement rates in the specialties. The consensus method shows the desired direct linear correlation of income with both length of the physician's work week and intensity of effort. It rates the primary care specialties as a group more highly than the RBRVS.

CONCLUSION:The proposed consensus method meets the original intent of the RBRVS to reimburse physicians on the basis of the resource input of time as modified by the criteria of Hsiao et al.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:Ghana introduced capitation payment for primary care in 2012 with the view to containing escalating claims expenditure. This shift in provider payment method raised issues about its potential impact on patient-provider trust relationship and insured-patients' trust in the Ghana National Health Insurance Scheme. This paper presents findings of a study that explored insured-patients' perception about, and attitude towards capitation payment in Ghana; and determined whether capitation payment affect insured-patients' trust in their preferred primary care provider and the National Health Insurance Scheme in general. METHODS:We adopted a survey design for the study. We administered closed-ended questionnaires to collect data from insurance card-bearing members aged 18 years and above. We performed both descriptive statistics to determine proportions of observations relating to the variables of interest and chi-square test statistics to determine differences within gender and setting. RESULTS:Sixty-nine per cent (69 %) out of 344 of respondents selected hospital level of care as their primary care provider. The two most important motivations for the choice of a provider were proximity in terms of geographical access (40 %) and perceived quality of care (38 %). Eighty-eight per cent (88 %) rated their trust in their provider as (very) high. Eighty-two per cent (82 %) actively selected their providers. Eighty-eight per cent (88 %) had no intention to switch provider. A majority (91 %) would renew their membership when it expires. Female respondents (91 %; n = 281) were more likely to renew their membership than males (87 %; n = 63). Notwithstanding capitation payment experience, 81 % of respondents would recommend to their peers to enrol with the NHIS with rural dwellers (87 %; n = 156) being more likely to do so than urban dwellers (76 %; n = 188). Almost all respondents (92 %) rated the NHIS as (very) good. CONCLUSION:Health Insurance subscribers in Ghana have high trust in their primary care provider giving them quality care under capitation payment despite their negative attitude towards capitation payment. They are guided by proximity and quality of care considerations in their choice of provider. The NHIA would, however, have to address itself to the negative perceptions about the capitation payment policy.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:It is widely believed that the method of payment of physicians may affect their clinical behaviour. Although payment systems may be used to achieve policy objectives (e.g. cost containment or improved quality of care), little is known about the effects of different payment systems in achieving these objectives. OBJECTIVES:To evaluate the impact of different methods of payment (capitation, salary, fee for service and mixed systems of payment) on the clinical behaviour of primary care physicians (PCPs). SEARCH STRATEGY:We searched the Cochrane Effective Practice and Organisation of Care Group specialised register; the Cochrane Controlled Trials Register; MEDLINE (1966 to October 1997); BIDS EMBASE (1980 to October 1997); BIDS ISI (1981 to October 1997); EconLit (1969 to October 1997); HealthStar (1975 to October 1997) Helmis (1984 to October 1997); health economics discussion paper series of the Universities of York, Aberdeen, Sheffield, Bristol, Brunel, and McMaster; Swedish Institute of Health Economics; RAND corporation; and reference lists of articles. SELECTION CRITERIA:Randomised trials, controlled before and after studies and interrupted time series analyses of interventions comparing the impact of capitation, salary, fee for service (FFS) and mixed systems of payment on primary care physician satisfaction with working environment; cost and quantity of care; type and pattern of care; equity of care; and patient health status and satisfaction. DATA COLLECTION AND ANALYSIS:Two reviewers independently extracted data and assessed study quality. MAIN RESULTS:Four studies were included involving 640 primary care physicians and more than 6400 patients. There was considerable variation in study setting and the range of outcomes measured. FFS resulted in more primary care visits/contacts, visits to specialists and diagnostic and curative services but fewer hospital referrals and repeat prescriptions compared with capitation. Compliance with a recommended number of visits was higher under FFS compared with capitation payment. FFS resulted in more patient visits, greater continuity of care, higher compliance with a recommended number of visits, but patients were less satisfied with access to their physician compared with salaried payment. REVIEWER'S CONCLUSIONS:It is noteworthy that so few studies met the inclusion criteria. There is some evidence to suggest that the method of payment of primary care physicians affects their behaviour, but the findings' generalisability is unknown. More evaluations of the effect of payment systems on PCP behaviour are needed, especially in terms of the relative impact of salary versus capitation payments.

背景与目标：

BACKGROUND & AIMS: :This study analyzed the early effects of the Medicare Prospective Payment System (PPS) on the likelihood of hospital's discharging Medicare beneficiaries to skilled nursing facilities (SNFs), intermediate care facilities (ICFs), and home health agencies. It also examined length of stay before transfer. Discharge abstract data on patients in five DRG groups were studied. Data were obtained from 501 hospitals for the third quarters of 1980, 1983, 1984, and 1985. Multinomial logit and ordinary least squares regression techniques were employed. After controlling for hospital and patient characteristics, including severity of illness, it was found that the probability of transfer increased substantially in virtually all DRGs and discharge destinations studied. This was particularly true for patients with stroke, pneumonia, and major joint and hip procedure. The analysis reveals that PPS increased the rate of discharges to subacute facilities. This effect was stronger for transfer to SNFs than to ICFs and home health agencies. Further, the impact of PPS on transfers was greater in 1985 than in 1984. Lengths of stay before transfer tended to decline in almost all DRGs and destinations examined. However, the effects of PPS on lengths of stay of transferred patients were not statistically significant at conventional levels. The results suggest that payment experiments with broader forms of bundled services are in order, as are experiments with hospital acute-subacute swing beds.

背景与目标： : 这项研究分析了医疗保险预期支付系统 (PPS) 对医院将医疗保险受益人送往熟练护理机构 (snf)，中级护理机构 (icf) 和家庭保健机构的可能性的早期影响。它还检查了转移前的停留时间。出院摘要研究了五个DRG组患者的数据。数据来自1980年、1983、1984和1985第三季度的501家医院。采用多项式logit和普通最小二乘回归技术。在控制了医院和患者的特征 (包括疾病的严重程度) 之后，发现在几乎所有研究的drg和出院目的地中，转移的可能性都大大增加了。对于中风，肺炎以及主要关节和髋关节手术的患者尤其如此。分析表明，PPS增加了亚急性设施的排放率。这种效果对于转移到snf比转移到icf和家庭保健机构更强。此外，PPS对转移的影响1985年大于1984年。在几乎所有检查的drg和目的地中，转移前的停留时间都趋于减少。然而，在常规水平下，PPS对转移患者住院时间的影响在统计学上并不显着。结果表明，使用更广泛形式的捆绑服务进行支付实验，以及使用医院急性亚急性秋千床进行的实验也是如此。

BACKGROUND & AIMS: :The idea that payment for research participation can be coercive appears widespread among research ethics committee members, researchers, and regulatory bodies. Yet analysis of the concept of coercion by philosophers and bioethicists has mostly concluded that payment does not coerce, because coercion necessarily involves threats, not offers. In this article we aim to resolve this disagreement by distinguishing between two distinct but overlapping concepts of coercion. Consent-undermining coercion marks out certain actions as impermissible and certain agreements as unenforceable. By contrast, coercion as subjection indicates a way in which someone's interests can be partially set back in virtue of being subject to another's foreign will. While offers of payment do not normally constitute consent-undermining coercion, they do sometimes constitute coercion as subjection. We offer an analysis of coercion as subjection and propose three possible practical responses to worries about the coerciveness of payment.

背景与目标： : 在研究伦理委员会成员，研究人员和监管机构中，对研究参与的付款可能具有强制性的想法似乎很普遍。然而，哲学家和生物伦理学家对胁迫概念的分析大多得出结论，付款不会胁迫，因为胁迫必然涉及威胁，而不是要约。在本文中，我们旨在通过区分两个不同但重叠的胁迫概念来解决这种分歧。破坏同意的胁迫将某些行为标记为不允许的，将某些协议标记为不可执行的。相比之下，胁迫作为服从表明某人的利益可以由于服从他人的外国意愿而部分退缩。虽然付款要约通常不构成破坏同意的胁迫，但有时确实构成胁迫。我们对胁迫作为服从进行了分析，并提出了三种可能的实际对策，以解决对支付强制性的担忧。

BACKGROUND & AIMS: :Erythropoiesis-stimulating agents (ESAs) are commonly used to treat anemia in patients with CKD, including those receiving dialysis, although clinical trials have identified risks associated with ESA use. We evaluated the effects of changes in dialysis payment policies and product labeling instituted in 2011 on mortality and major cardiovascular events across the United States dialysis population in an open cohort study of patients on dialysis from January 1, 2005, through December 31, 2012, with Medicare as primary payer. We compared observed rates of death and major cardiovascular events in 2011 and 2012 with expected rates calculated on the basis of rates in 2005-2010, accounting for differences in patient characteristics and influenza virulence. An abrupt decline in erythropoietin dosing and hemoglobin concentration began in late 2010. Observed rates of all-cause mortality, cardiovascular mortality, and myocardial infarction in 2011 and 2012 were consistent with expected rates. During 2012, observed rates of stroke, venous thromboembolic disease (VTE), and heart failure were lower than expected (absolute deviation from trend per 100 patient-years [95% confidence interval]: -0.24 [-0.08 to -0.37] for stroke, -2.43 [-1.35 to -3.70] for VTE, and -0.77 [-0.28 to -1.27] for heart failure), although non-ESA-related changes in practice and Medicare payment penalties for rehospitalization may have confounded the results. This initial evidence suggests that action taken to mitigate risks associated with ESA use and changes in payment policy did not result in a relative increase in death or major cardiovascular events and may reflect improvements in stroke, VTE, and heart failure.

背景与目标： : 红细胞生成刺激剂 (ESAs) 通常用于治疗CKD患者的贫血，包括接受透析的患者，尽管临床试验已经确定了与ESA使用相关的风险。我们在一项从2005年1月1日到2012年12月31日的透析患者的开放队列研究中，评估了2011年制定的透析支付政策和产品标签的变化对美国透析人群死亡率和主要心血管事件的影响，其中Medicare是主要付款人。我们比较了观察到的死亡率和主要心血管事件2011年和2012的发生率与根据2005-2010年的发生率计算的预期发生率，考虑了患者特征和流感毒力的差异。2010年开始促红细胞生成素剂量和血红蛋白浓度突然下降。观察到的全因死亡率，心血管死亡率和心肌梗死2011年和2012与预期的比率一致。在2012期间，观察到的中风，静脉血栓栓塞性疾病 (VTE) 和心力衰竭的发生率低于预期 (与每100患者趋势的绝对偏差-年 [95% 置信区间]: -0.24 [-0.08至-0.37] 中风，-VTE的2.43 [-1.35至-3.70] 和心力衰竭的0.77 [-0.28至-1.27])，尽管实践中的非ESA相关变化和重新住院的Medicare付款罚款可能会混淆结果。这一初步证据表明，为减轻与ESA使用和支付政策变化相关的风险而采取的措施并未导致死亡或主要心血管事件的相对增加，并且可能反映了中风，VTE和心力衰竭的改善。