Original Investigation
Dialysis
Early Trends From the Study to Evaluate the Prospective Payment System Impact on Small Dialysis Organizations (STEPPS)

https://doi.org/10.1053/j.ajkd.2012.11.040Get rights and content

Background

Launched in January 2011, the prospective payment system (PPS) for the US Medicare End-Stage Renal Disease Program bundled payment for services previously reimbursed independently. Small dialysis organizations may be particularly susceptible to the financial implications of the PPS. The ongoing Study to Evaluate the Prospective Payment System Impact on Small Dialysis Organizations (STEPPS) was designed to describe trends in care and outcomes over the period of PPS implementation. This report details early results between October 2010 and June 2011.

Study Design

Prospective observational cohort study of patients from a sample of 51 small dialysis organizations.

Setting & Participants

1,873 adult hemodialysis and peritoneal dialysis patients.

Outcomes

Secular trends in processes of care, anemia, metabolic bone disease management, and red blood cell transfusions.

Measurements

Facility-level data are collected quarterly. Patient characteristics were collected at enrollment and scheduled intervals thereafter. Clinical outcomes are collected on an ongoing basis.

Results

Over time, no significant changes were observed in patient to staff ratios. There was a temporal trend toward greater use of peritoneal dialysis (from 2.4% to 3.6%; P = 0.09). Use of cinacalcet, phosphate binders, and oral vitamin D increased; intravenous (IV) vitamin D use decreased (P for trend for all <0.001). Parathyroid hormone levels increased (from 273 to 324 pg/dL; P < 0.001). Erythropoiesis-stimulating agent doses decreased (P < 0.001 for IV epoetin alfa and IV darbepoetin alfa), particularly high doses. Mean hemoglobin levels decreased (P < 0.001), the percentage of patients with hemoglobin levels <10 g/dL increased (from 12.7% to 16.8%), and transfusion rates increased (from 14.3 to 19.6/100 person-years; P = 0.1). Changes in anemia management were more pronounced for African American patients.

Limitations

Limited data were available for the prebundle period. Secular trends may be subject to the ecologic fallacy and are not causal in nature.

Conclusions

In the period after PPS implementation, IV vitamin D use decreased, use of oral therapies for metabolic bone disease increased, erythropoiesis-stimulating agent use and hemoglobin levels decreased, and transfusion rates increased numerically.

Section snippets

Study Design

STEPPS is a multicenter prospective observational cohort study of 51 dialysis facilities that are members of SDOs within the United States. An SDO was defined as a dialysis provider that was either a stand-alone facility or part of a chain that included 50 or fewer facilities.

Facility Selection

Potential facilities were identified according to a database that included all free-standing US dialysis facilities that (circa 2006) qualified as SDOs according to the mentioned criteria. All potential facilities (n =

Facility Selection and Facility Characteristics

A schematic illustrating how STEPPS facilities were selected is shown in Fig 1. STEPPS includes a sample of 51 dialysis facilities (∼5% of all SDO facilities in the United States). All were still participating as of June 30, 2011; none had been acquired by a large dialysis organization. Of enrolled facilities, 77% opted fully into the PPS in 2011; most of their patients (mean, 68%) have Medicare as their primary payer, with the next-largest group including those with commercial insurance (mean,

Discussion

STEPPS is a prospective cohort study designed to assess the evolution of care within SDOs during implementation of the PPS. In this early report, we describe the assembly of the STEPPS cohort, examine the representativeness of STEPPS facilities and patients compared to the broader SDO population in the United States, and report on trends in certain aspects of dialytic care during the initial phase of PPS implementation. We observed a modest increase in the use of PD over time. There were more

Acknowledgements

We acknowledge the great efforts and contributions of the site investigators and study participants from the 51 dialysis facilities that are participating in STEPPS; Irene Agodoa and Lei Lei for contributions to the design and implementation of the study; and Wendy Ma and Fangfei Chen for assistance with statistical programming.

Support: Support for STEPPS was provided by Amgen Inc.

Financial Disclosure: Dr Brunelli's spouse is employed by AstraZeneca; he previously served on advisory boards for

References (21)

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Originally published online January 17, 2013.

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