Economic Evaluation of a Pre-ESRD Pay-for- Performance Program in Advanced Chronic Kidney Disease Patients Hsieh, Hui-Min, Ph.D. Associate Professor at Department of Public Health, Kaohsiung Medical University, Taiwan Co-authors: Lin, M. Y., Chiu, Y. W., Wu, P. H., Cheng, L.J, Jian, F. S., Hsu, C. C., and Hwang, S. J. Acknowledgement: This project was funded by National Health Insurance Administration, Ministry of Health and Welfare (M0HW103-NH-1001), Kaohsiung Medical University Hospital (KMUH103-3R10) and Ministry of Science and Technology (MOST-103-2314-B-037-001). 1
Introduction End-stage renal disease (ESRD) is a major cause of morbidity and mortality worldwide. The number of patients with ESRD receiving renal replacement therapy (RRT) is projected to grow from 2,618 million in 2010 to 5,439 million worldwide by 2030. One of the key concerns is that these patients consume a substantial share of national health care resources. Therefore, it became a key priority to identify strategies to provide optimization of pre-ESRD care for chronic kidney disease (CKD) patients in order to delay progression to ESRD, improve patient survival and reduce economic costs. 2
Pre-ESRD P4P program Taiwan has high incidence and prevalence rate of ESRD and undertakes a substantial economic burden from this disease. A nationwide pre-ESRD Pay-for-performance (P4P) program was launched under the National Health Insurance Administration (NHIA) coverage in late 2006. The primary goals for this program are: • To provide adequate care for CKD stage 3b, 4 and 5 patients • To slow down the deterioration of renal function • To reduce incidence of ESRD • To provide early preparations for dialysis • To potentially reduce substantial health expenditure 3
Key Features of the Pre-ESRD P4P Program Multidisciplinary care team ： at least one nephrologist as well as well-trained renal nurses and dieticians). Require to follow guidelines of the National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-K/DOQI) for the standard care of patients. Regular follow-up care every 3 months Financial Incentives ： an extra NT$1,200 (US$40) per initial enrollment visit, NT$600 (US$20) per follow-up visit, and NT$600 (US$20) per annual evaluation visit. 4
Objectives To investigate ： Whether the nationwide pre-ESRD P4P program reduced the risks of all-cause mortality and dialysis initiation for advanced CKD paitents. Whether the program allowed for a cost-effective use of resources among advanced CKD patients from a single payer perspective. 5
Data Sources Nationwide Pre-ESRD P4P registry ： precisely identifying whether patients were enrolled in the P4P program NHIA claims database ： obtaining information on patient comorbidities and health provider characteristics. A registry of catastrophic illnesses ： providing information for a long-term dialysis ESRD patients and the date on which dialysis began. Death registry data ： providing accurate date of death information 6
Study Population To identify pre-ESRD patients if he or she had the first three primary diagnosis codes [ICD-9-CM] codes 585 or 581.9 given the Pre-ESRD P4P program policies in at least one outpatient visit or inpatient admission and was followed by nephrologists between January 1, 2007 and December 31, 2009. Defined advanced CKD patients for those who had received ESA treatment within two years, one year prior and post, of the index date given the NHIA reimbursement policy regulated that advanced CKD patients who have serum creatinine >6 mg/dL and a hematocrit <28% could receive an erythropoiesis-stimulating agent (ESA). P4P/ Non-P4P group: newly enrolled P4P patients in the P4P registry; Non-P4P group: who were not found to be enrolled in the P4P program. 7
Outcomes of Interest Effectiveness: ◦ Presence of ESRD warranting renal replacement therapy (RRT) initiation; ◦ Mortality due to any cause were the primary end-points. ◦ Life years gained Direct medical costs: ◦ From a single payer perspective. 3% discount rate. ◦ CKD related medical costs ◦ Other-cause medical costs ◦ Costs were measured separately for patients who progressed to ESRD and underwent dialysis or not during the follow-up period. Time Horizon: 3 years 8
Economic and Statistical Analytical Approach Propensity score matching (PSM) approach to determine adequate comparison groups. The covariates included age, gender, income status, urbanization, pre-ESRD related comorbidities, charlson comorbidity index, health care institution characteristics (accreditation level, teaching status, and geographic location). Competing-risk regression models based on cause-specific and subdistribution hazards were used to analyze the association between the effect of pre-ESRD P4P program and two primary effectiveness end-points. Cost-effectiveness analysis Incremental cost effectiveness ratio (ICER) as the ratio of the difference in costs and divided by the difference in effectiveness between groups. Bootstrapping with 500 replications. 9
Incremental cost effectiveness ratio (ICER) 10
Descriptive results for P4P and non-P4P pre-ESRD patient characteristics (before and after matching) Before PSM matching After PSM matching Variables P4P Non-P4P p-value P4P Non-P4P p-value 2,093 2,161 1,473 1,473 N Patient Demographic Characteristics Gender (N, %) Female 0.796 1,082 (51.70%) 1,123 (51.97%) 0.859 743 (50.44%) 750 (50.92%) Male 1,011 (48.30%) 1,038 (48.03%) 730 (49.56%) 723 (49.08%) Age in years (mean ± SD) 64.37 ( ± 13.62) 64.57 ( ± 13.78) 63.79 ( ± 13.52) 64.87 ( ± 13.70) 0.693 0.010 Income Status(N, %) 1-19999 0.687 423 (20.21%) 505 (23.37%) 0.092 346 (23.49%) 326 (22.13%) Dependents 714 (34.11%) 707 (32.72%) 489 (33.20%) 478 (32.45%) 20000-39999 812 (38.80%) 813 (37.62%) 537 (36.46%) 561 (38.09%) 40000+ 144 (6.88%) 136 (6.29%) 101 (6.86%) 108 (7.33%) Urbanization (N, %) Rural 0.711 587 (28.05%) 624 (28.88%) 0.548 403 (27.36%) 412 (27.97%) Urban 1,506 (71.95%) 1,537 (71.12%) 1,070 (72.64%) 1,061 (72.03%) Patient Clnical Characteristics Pre-ESRD related comobidities (N, %) Diabetes 727 (49.36%) 747 (50.71%) 0.461 1,051 (50.22%) 1,048 (48.50%) 0.262 Hyptertension 1,148 (77.94%) 1,152 (78.21%) 0.859 1,637 (78.21%) 1,648 (76.26%) 0.129 MI 0.865 28 (1.34%) 22 (1.02%) 0.333 17 (1.15%) 18 (1.22%) CHF 194 (13.17%) 201 (13.65%) 0.705 238 (11.37%) 306 (14.16%) 0.006 Stroke 106 (7.20%) 121 (8.21%) 0.300 138 (6.59%) 182 (8.42%) 0.023 Gout 257 (17.45%) 254 (17.24%) 0.884 369 (17.63%) 387 (17.91%) 0.812 PVD 0.542 80 (3.82%) 73 (3.38%) 0.436 47 (3.19%) 53 (3.60%) Charlson Comobidity Index (Mean ± SD) 4.09 ( ± 2.08) 4.11 ( ± 2.11) 4.16 ( ± 2.04) 4.00 ( ± 2.16) 0.785 0.014 11
Descriptive results for incidence of dialysis and all-cause mortality between matched P4P and non-P4P pre-ESRD cohorts within 3-year follow-ups Non- Matched Sample P4P Non-P4P P4P Non-P4P P4P P4P Incidence rate/ Incidence of dialysis and Incidence rate/ Incidence rate ratio mortality rate comparisons mortality mortality rate No. of total person-years p- per 1000 p-value N (%) N (%) (95%CI) value person-years N 1,473 1,473 <0.001 Incidence of dialysis 2,188 1,853 1,163 1,173 0.649 531.52 632.98 0.84 (78.95%) (79.63%) (0.77, 0.91) 0.003 All-cause mortality 4,102 3,955 283 341 0.009 68.99 86.23 0.80 (0.68, 0.93) (19.21%) (23.15%) Time-to-event comparisons P4P Non-P4P p-value 430.95 347.26 Time to dialysis (in days) <0.001 ( ± 293.83) ( ± 297.45) 682.22 595.17 Time to death (in days) <0.001 ( ± 280.79) ( ± 285.58) Percent of receiving PD (N,%)* 183 (15.74%) 142 (12.11%) 0.011 Note: HD=hemodialysis; PD=peritoneal dialysis Percent of receiving HD (N,%)* 980 (84.26%) 1,031 (87.89%) 0.011 * Only for patients who underwent dialysis after enrollment into the P4P program 12
Results from Competing-risk regression analysis of death and dialysis Incidence of dialysis All-cause mortality SHR SHR Variables p-value p-value 95%CI 95%CI Policy effect 0.845 0.792 P4P (0.779,0.916) <0.001 (0.673,0.932) 0.005 * Models were adjusted for age, gender, income status, urbanization, patient comorbidities listed in Table 1. 13
2 All-cause Mortality Initiation of Dialysis .2 1.5 .15 Cumulative Incidence 1 .1 SHR=0.792 (P4P vs Non-P4P) SHR=0.845 (P4P v.s. Non-P4P) .5 .05 (95%CI=0.779, 0.916) 95%CI=0.673, 0.932 p-value<0.001 p-value=0.005 0 0 0 1 2 3 0 1 2 3 Follow-up time (in years) Follow-up time (in years) Non-P4P P4P Non-P4P P4P Fig1. Adjusted cumulative incidence curve for risks of death and dialysis initiation between P4P and non- P4P advanced CKD cohorts 14
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