Microbial Transfer by Intermittent Catheters: An In Vitro Evaluation of Microbial Transfer in Catheter With Variable Protective Features.

PURPOSE: The purpose of this study was to evaluate the effects of various protective features (eg, catheter cap, introducer tip, and catheter sleeve) of hydrophilic intermittent catheters against contamination with urinary tract infection-associated microorganisms using an in vitro model. DESIGN: An in vitro study of microbial transfer. MATERIALS AND METHODS: Gloves were contaminated with uropathogenic microorganisms and used to simulate intermittent catheterization of male anatomical models with and without the protective features present in 5 commercially available hydrophilic catheters. Using this contaminated touch transfer method, both the meatus of the sterile male anatomical models and sterile surgical gloves of an operator were inoculated with a high level of microorganisms (107 and 109 colony-forming units [CFU], respectively). The operator then performed catheterization of the anatomical model. The most relevant segments of the catheter were sampled, and the level of microbial transfer and catheter contamination was quantified. Results from experimental and sample replicates from the 3 microbial species and 5 catheters (sleeved and unsleeved) were analyzed by pair-wise t tests and analysis of variance. RESULTS: Of the 5 commercially available sleeved intermittent catheters evaluated in this study, use of catheters with multiple protective components (ring cap, introducer tip, and catheter sleeve) resulted in significant improvement in protection against contamination with a 25- to 2500-fold lower level of microbial contamination (C1 segment) across all species as compared to catheters protected with only sleeves or un-sleeved catheters. CONCLUSIONS: The combination of a ring cap, protective introducer tip, and protective sleeve provides additional protection when compared to sleeve alone from transferring microbial contamination from the meatus to the advancing catheter. Additional research is needed to determine whether these design features result in fewer urinary tract infections among intermittent catheter users.

Characteristics, Hospital Length of Stay, and Readmissions Among Individuals Undergoing Abdominal Ostomy Surgery: Review of a Large US Healthcare Database.

PURPOSE: The purpose of this study was to examine patient characteristics, length of stay (LOS), hospital revisits, and complications of patients undergoing abdominal ostomy surgery. DESIGN: Retrospective cohort study. SUBJECTS AND SETTING: Data were extracted from the PINC AI Healthcare Database (PHD), a large archive that stores data from 25% of all US inpatient hospital discharges. Patients were admitted to 658 hospitals in the United States between December 1, 2017, and November 30, 2018. The sample comprised 27,658 adult patients; 15,512 underwent creation of a colostomy, 10,207 underwent ileostomy construction, and 1930 had a urostomy procedure. Their median age was 64 years (interquartile range [IQR] = 19 years). Emergent admission type was 71.2% for patients who underwent a colostomy procedure, 49.4% for ileostomy, and 9.9% for urostomy. The majority of patients underwent open surgery (77.7%); 22.3% of procedures used an endoscopic approach. METHODS: Patients were identified as having undergone abdominal ostomy surgery via ICD-10-PCS (International Classification of Diseases, Tenth Revision, Procedure Coding System) procedure codes. Demographic, visit, hospital and clinical characteristics, LOS, and hospital revisits (ie, readmissions and emergency department [ED]) were captured for qualifying patients. Data were evaluated using unadjusted descriptive analyses. RESULTS: The median LOS of 9 days (IQR = 9 days) varied by ostomy surgery; the cumulative postsurgical LOS was 7 days (IQR = 5 days). The most frequent underlying diagnoses resulting in ostomy surgery were diverticulitis of the large bowel (19.6%) managed by colostomy, colorectal cancer managed by ileostomy (22.5%), or urothelial cancer managed by urostomy (78.1%). Slightly less than a quarter (23.7%) of patients were discharged home without home care, 43.0% went home with home healthcare, and 29.6% were discharged to a non-acute care facility. Hospital readmission within 120 days of discharge was 36.3% for patients with a colostomy, 52.3% for those with an ileostomy, and 34.6% for patients with a urostomy. Ostomy complications were identified as the reason for readmission in 62.4% of patients. Slightly more than 1 in 5 patients (20.7%) had a subsequent ED visit within 120 days, 39.7% of which involved ostomy complication. CONCLUSIONS: Characteristics of patients undergoing abdominal stoma surgery varied based on underlying diagnosis and ostomy type. The median hospital LOS was more than 1 week. Patients experienced high rates of healthcare utilization (hospital admission or ED visits) during the 120 days following surgery.

Incidence of urinary tract infection following initiation of intermittent catheterization among patients with recent spinal cord injury in Germany and the Netherlands.

Objective: To assess incidence of urinary tract infection (UTI) among patients with recent spinal cord injury (SCI) who initiated intermittent catheterization (IC).Design: Retrospective chart review.Setting: Two European SCI rehabilitation centers.Participants: Seventy-three consecutive patients with recent SCI who initiated IC.Outcome measures: Incidence of UTI, using six different definitions, each based on microbiology ± symptomatology ± mention of UTI . Rates were expressed in terms of numbers of UTIs per 100 patient-months (PMs). Attention was focused on first-noted UTI during the three-month follow-up, as assessed with each of the six definitions.Results: Fifty-eight percent of patients (n = 33) met ≥1 definitions for UTI during follow-up (rate: 31.5 UTIs per 100 PMs), ranging from 14% (5.3 per 100 PMs; definition requiring bacteriuria, pyuria, and presence of symptoms) to 45% (22.7 per 100 PMs; definition requiring "mention of UTI"). Ten cases were identified using the definition that required bacteriuria, pyuria, and symptoms, whereas definitions that required bacteriuria and either pyuria or symptoms resulted in the identification of 20-25 cases. Median time to UTI ranged from 42 days ("mention of UTI") to 81 days (definition requiring bacteriuria and ≥100 leukocytes/mm3).Conclusion: Depending on definition, 14% to 45% of patients with recent SCI experience UTI within three months of initiating IC. Definitions requiring bacteriuria and either pyuria or symptoms consistently identified about twice as many cases as those that required all three conditions. Standardizing definitions may help improve detection, treatment, and prevention of UTI within this vulnerable population.

Evolving Evidence Supporting Use of Rectal Irrigation in the Management of Bowel Dysfunction: An Integrative Literature Review.

Disorders of bowel function are prevalent, particularly among patients with spinal cord injuries and other neurological disorders. An individual's bowel control significantly impacts quality of life, as predictable bowel function is necessary to actively and independently participate in everyday activities. For many patients with bowel dysfunction, initial lifestyle adjustments and other conservative therapeutic interventions (eg, digital stimulation, oral laxatives, suppositories) are insufficient to reestablish regular bowel function. In addition to these options, rectal irrigation (RI) is a safe and effective method of standard bowel care that has been used for several decades in adults and children suffering from bowel dysfunction associated with neurogenic or functional bowel etiologies. Rectal irrigation is an appropriate option when conservative bowel treatments are inadequate. Unlike surgical options, RI can be initiated or discontinued at any time. This report summarizes the clinical, humanistic, and economic evidence supporting the use of RI in clinical practice, noting features (eg, practical considerations, patient education) that can improve patients' success with RI treatment.

The burden of illness in initiating intermittent catheterization: an analysis of German health care claims data.

BACKGROUND: Intermittent catheterization (IC) is a common medical technique to drain urine from the bladder when this is no longer possible by natural means. The objective of this study was to evaluate the standard of care and the burden of illness in German individuals who perform intermittent catheterization and obtain recommendations for improvement of care. METHODS: A descriptive study with a retrospective, longitudinal cohort design was conducted using the InGef research database from the German statutory health insurance claims data system. The study consisted of individuals with initial IC use in 2013-2015. RESULTS: Within 3 years 1100 individuals with initial IC were identified in the database (~ 19,000 in the German population). The most common IC indications were urologic diseases, spinal cord injury, Multiple Sclerosis and Spina Bifida. Urinary tract infections (UTI) were the most frequent complication occurring 1 year before index (61%) and in follow-up (year 1 60%; year 2 50%). Resource use in pre-index including hospitalizations (65%), length of stay (12.8 ± 20.0 days), physician visits (general practitioner: 15.2 ± 29.1), prescriptions of antibiotics (71%) and healthcare costs (€17,950) were high. Comorbidities, complications, and healthcare resource use were highest 1 year before index, decreasing from first to second year after index. CONCLUSIONS: The data demonstrated that prior to initial catheterization, IC users experienced UTIs and high healthcare utilization. While this demonstrates a potential high burden of illness prior to initial IC, UTIs also decreased over time, suggesting that IC use may have a positive influence. The findings also showed that after the first year of initial catheterization the cost decreased. Further studies are needed to better understand the extent of the burden for IC users compared to non-IC users.

A Patient-Centric Tool to Facilitate Goal Attainment Scaling in Neurogenic Bladder and Bowel Dysfunction: Path to Individualization.

OBJECTIVES: People with neurogenic bladder and/or bowel dysfunction experience diverse challenges that can be difficult to evaluate with standardized outcome measures. Goal attainment scaling (GAS) is an individualized, patient-centric outcome measure that enables patients/caregivers to identify and track their own treatment goals. Because creating goals de novo can be cumbersome, we aimed to develop a neurogenic bladder/bowel dysfunction goal menu to facilitate goal attainment scaling uptake and use. METHODS: We conducted a workshop with 6 expert clinicians to develop an initial menu. Individual interviews with 12 people living with neurogenic bladder and/or bowel dysfunction and 2 clinician panels with 5 additional experts aided us in refining the menu. A thematic framework analysis identified emergent themes for analysis and reporting. RESULTS: Interview participants were adults (median = 36 years, range 25-58), most with spinal cord injury (75%; 9/12). Of 24 goals identified initially, 2 (8%) were not endorsed and were removed, and 3 goals were added. Most participants listed "Impact on Life" goals (eg, Exercise, Emotional Well-Being) among their 5 most important goals (58%; 35/60). Three main themes emerged: challenges posed by incontinence, limitations on everyday life, and need for personalized care. CONCLUSIONS: We developed a clinical outcome assessment tool following a multistep process of representative stakeholder engagement. This patient-centric tool consists of 25 goals specific to people living with neurogenic bladder and/or bowel dysfunction. Asking people what matters most to them can identify important constructs that clinicians might have overlooked.

A multinational evaluation assessing the relationship between peristomal skin health and health utility.

BACKGROUND:: irritation to peristomal skin remains one of the most prevalent ostomy-related complications influencing an individual's health status and quality of life. AIMS:: to assess the impact of damaged peristomal skin on the health utility and quality-adjusted life days (QALD) in an international adult ostomy population. METHODS:: a cross-sectional survey incorporating the SF-6D preference-based health utility index was developed to assess a random selection of post-surgical patients. FINDINGS:: health utility decreased with increasing skin irritation among the three geographic groups. The total mean health utility of normal peristomal skin for the three groups dropped incrementally for mild, moderate, and severe irritation. There were no differences in health utility or QALDs between the three country groups. CONCLUSION:: improvement of peristomal skin health is associated with improvements to QALDs. Clinicians, caregivers and patients have the responsibility to address a critical unmet need in skin health through interventions and products designed to support healthy peristomal skin.

Risk and Economic Burden of Peristomal Skin Complications Following Ostomy Surgery.

PURPOSE: The purpose of this study was to examine the incidence and economic burden of peristomal skin complications (PSCs) following ostomy surgery. DESIGN: Retrospective cohort study based on electronic health records and administrative data stores at a large US integrated healthcare system. SUBJECTS AND SETTINGS: The sample comprised 168 patients who underwent colostomy (ICD-9-CM 46.1X) (n = 108), ileostomy (46.2X) (n = 40), cutaneous ureteroileostomy (56.5X), or other external urinary diversion (56.6X) (n = 20) between January 1, 2012, and December 31, 2014. The study setting was an integrated health services organization that serves more than 2 million persons in the northeastern United States. METHODS: We scanned electronic health records of all study subjects to identify those with evidence of PSCs within 90 days of ostomy surgery and then examined healthcare utilization and costs over 120 days, beginning with date of surgery, among patients with and without evidence of PSCs. Testing for differences in continuous measures between the 3 ostomy groups was based on one-way analysis of variance; testing for differences in such measures between the PSC and non-PSC groups was based on a t statistic, and the χ statistic was used to test for differences in categorical measures. RESULTS: Sixty-one subjects (36.3%) had evidence of PSCs within 90 days of ostomy surgery (ileostomy, 47.5%; colostomy, 36.1%; urinary diversion, 15.0%; P < .05 for differences between groups). Among patients with evidence of PSCs, the mean (SD) time from surgery to first notation of this complication was 26.4 (19.0) days; it was 24.1 (13.2) days for ileostomy, 27.2 (21.1) days for colostomy, and 31.7 (25.7) days for urinary diversion (P = .752). Patients with PSCs were more likely to be readmitted to hospital by day 120 (55.7% vs 35.5% for those without PSCs; P = .011). The mean length of stay for patients readmitted to hospital was 11.0 days for those with PSCs and 6.8 days for those without PSCs (P = .111). The mean total healthcare cost over 120 days was $58,329 for patients with evidence of PSCs and $50,298 for those without evidence of PSCs (P = .251). CONCLUSIONS: Approximately one-third of ostomy patients developed PSCs within 90 days of their surgery. Peristomal skin complications are associated with a greater likelihood of hospital readmission. Our findings corroborate results of earlier studies.

Cost-effectiveness of a Ceramide-Infused Skin Barrier Versus a Standard Barrier: Findings From a Long-Term Cost-effectiveness Analysis.

PURPOSE: To assess the cost-effectiveness of a ceramide-infused skin barrier (CIB) versus other skin barriers (standard of care) among patients who have undergone ostomy creation. DESIGN: Cost-effectiveness analysis, based on a decision-analytic model that was estimated using data from the ADVOCATE (A Study Determining Variances in Ostomy Skin Conditions And The Economic Impact) trial, which investigated stoma-related healthcare costs over 12 weeks among patients who recently underwent fecal ostomy, and from other sources. SUBJECTS AND SETTING: Analysis was based on a hypothetical cohort of 1000 patients who recently underwent fecal ostomy; over a 1-year period, 500 patients were assumed to use CIB and 500 were assumed to use standard of care. METHODS: We adapted a previous economic model to estimate expected 1-year costs and outcomes among persons with a new ostomy assumed to use CIB versus standard of care. Outcomes of interest included peristomal skin complications (PSCs) (up to 2 during the 1-year period of interest) and quality-adjusted life days (QALDs); QALDs vary from 1, indicating a day of perfect health to 0, indicating a day with the lowest possible health (deceased). Subjects were assigned QALDs on a daily basis, with the value of the QALD on any given day based on whether the patient was experiencing a PSC. Costs included those related to skin barriers, ostomy accessories, and care of PSCs. The incremental cost-effectiveness of CIB versus standard of care was estimated as the incremental cost per PSC averted and QALD gained, respectively; net monetary benefit of CIB was also estimated. All analyses were run using the perspective of an Australian payer. RESULTS: On a per-patient basis, use of CIB was expected over a 1-year period to result in 0.16 fewer PSCs, an additional 0.35 QALDs, and a savings of A$180 (Australian dollars, US $137) in healthcare costs all versus standard of care. Management with CIB provided a net monetary benefit (calculated as the product of maximum willingness to pay for 1 QALD times additional QALDs with CIB less the incremental cost of CIB) of A$228 (US $174). Probabilistic sensitivity analysis was also completed; it revealed that 97% of model runs resulted in fewer expected PSCs with CIB; 92% of these runs resulted in lower expected costs with CIB. CONCLUSIONS: Findings suggest that the CIB is a cost-effective skin barrier for persons living with an ostomy.

The Burden of Peristomal Skin Complications on an Ostomy Population as Assessed by Health Utility and the Physical Component Summary of the SF-36v2®.

BACKGROUND: Body-altering surgery may affect perceptions of one's self. For those with abdominal stoma surgeries, altered perceptions amplified by peristomal skin condition can increase health burdens. OBJECTIVES: To assess health utility and health-related quality of life in an adult US ostomy sample in the presence of three levels of peristomal skin condition: intact, moderately compromised, and severely compromised. METHODS: The short form 36 health survey version 2, a generic health survey incorporating the six-dimensional health state short form preference-based utility index, was chosen to assess the sample. Analysis of covariance adjusted for age and time from surgery was used. RESULTS: The six-dimensional health state short form utilities for those with intact skin and physical component summary (PCS) levels indicating no physical limitations varied significantly from those with severely compromised skin and indicating the greatest degree of physical limitation (0.833 vs. 0.527). Peristomal skin condition decreases were associated with health utility decreases across all levels of the PCS. Because peristomal skin conditions are intermittent, the analysis presents quality-adjusted life-days (QALDs) per month. Ostomates with intact skin and PCS levels indicating no physical limitations demonstrated significant differences from those with severe skin condition and indicating the greatest degree of physical limitations (26.5 d/mo vs. 15.8 d/mo). As peristomal skin condition worsened, QALDs decreased across all levels of the PCS. A minimally important expected value of health was estimated to be an increase of 2.18 QALDs/mo. CONCLUSIONS: Successful treatment from a clinical perspective is more than the elimination of conditions-it is also a return of quality time to an individual.

Clinical and Economic Burden of Peristomal Skin Complications in Patients With Recent Ostomies.

PURPOSE: The purpose of this study was to estimate the risk and economic burden of peristomal skin complications (PSCs) in a large integrated healthcare system in the Midwestern United States. DESIGN: Retrospective cohort study. SUBJECTS AND SETTING: The sample comprised 128 patients; 40% (n = 51) underwent colostomy, 50% (n = 64) underwent ileostomy, and 10% (n = 13) underwent urostomy. Their average age was 60.6 ± 15.6 years at the time of ostomy surgery. METHODS: Using administrative data, we retrospectively identified all patients who underwent colostomy, ileostomy, or urostomy between January 1, 2008, and November 30, 2012. Trained medical abstractors then reviewed the clinical records of these persons to identify those with evidence of PSC within 90 days of ostomy surgery. We then examined levels of healthcare utilization and costs over a 120-day period, beginning with date of surgery, for patients with and without PSC, respectively. Our analyses were principally descriptive in nature. RESULTS: The study cohort comprised 128 patients who underwent ostomy surgery (colostomy, n = 51 [40%]; ileostomy, n = 64 [50%]; urostomy, n = 13 [10%]). Approximately one-third (36.7%) had evidence of a PSC in the 90-day period following surgery (urinary diversion, 7.7%; colostomy, 35.3%; ileostomy, 43.8%). The average time from surgery to PSC was 23.7 ± 20.5 days (mean ± SD). Patients with PSC had index admissions that averaged 21.5 days versus 13.9 days for those without these complications. Corresponding rates of hospital readmission within the 120-day period following surgery were 47% versus 33%, respectively. Total healthcare costs over 120 days were almost $80,000 higher for patients with PSCs. CONCLUSIONS: Approximately one-third of ostomy patients over a 5-year study period had evidence of PSCs within 90 days of surgery. Costs of care were substantially higher for patients with these complications.

EXPLORING PATENT ACTIVITY AND ITS POTENTIAL ASSOCIATION WITH HEALTHCARE OUTCOMES: A CASE STUDY OF OSTOMY PRODUCTS IN SWEDEN.

OBJECTIVES: The aim of this study was to evaluate whether ostomy industry patent activity (PA) is associated with patient outcomes and healthcare costs. METHODS: Two groups of ostomy pouch users based on manufacturer PA (low or high) were compared in terms of ostomy-related wear patterns, adverse events, and healthcare expenditure. Using Swedish registry data, all patients with newly formed stomas were divided between each group and were followed during a 2-year period (2011-12). Propensity score matching and parametric duration analysis were used to compare outcomes between patients of similar characteristics such as sex, age, and ostomy surgery type. RESULTS: In both one- and two-piece systems, the high PA group had significantly lower monthly ostomy-related expenditure than the low PA group (one-piece: 197.47 EUR versus 233.34 EUR; two-piece: 164.00 EUR versus 278.98 EUR). Fewer pouch and skin wafer purchases per month were an important driver of cost differences. Both groups had similar likelihood of purchasing dermatological products for skin complications over time. CONCLUSIONS: PA in the ostomy care industry was associated with reduced healthcare costs, but not necessarily with fewer skin complications. It suggests that there is a health economic benefit from products made by patent intensive companies which may differentiate them from generic comparators, but more research is needed to understand the impact of activities conducive to medical innovation on health outcomes.

A Cost-Utility Model of Care for Peristomal Skin Complications.

PURPOSE: The aim of this study was to evaluate the economic and humanistic implications of using ostomy components to prevent subsequent peristomal skin complications (PSCs) in individuals who experience an initial, leakage-related PSC event. DESIGN: Cost-utility analysis. METHODS: We developed a simple decision model to consider, from a payer's perspective, PSCs managed with and without the use of ostomy components over 1 year. The model evaluated the extent to which outcomes associated with the use of ostomy components (PSC events avoided; quality-adjusted life days gained) offset the costs associated with their use. RESULTS: Our base case analysis of 1000 hypothetical individuals over 1 year assumes that using ostomy components following a first PSC reduces recurrent events versus PSC management without components. In this analysis, component acquisition costs were largely offset by lower resource use for ostomy supplies (barriers; pouches) and lower clinical utilization to manage PSCs. The overall annual average resource use for individuals using components was about 6.3% ($139) higher versus individuals not using components. Each PSC event avoided yielded, on average, 8 additional quality-adjusted life days over 1 year. CONCLUSIONS: In our analysis, (1) acquisition costs for ostomy components were offset in whole or in part by the use of fewer ostomy supplies to manage PSCs and (2) use of ostomy components to prevent PSCs produced better outcomes (fewer repeat PSC events; more health-related quality-adjusted life days) over 1 year compared to not using components.

A Global Overview of the Impact of Peritoneal Dialysis First or Favored Policies: An Opinion.

Given the ever-increasing burden of end-stage renal disease (ESRD) in a global milieu of limited financial and health resources, interested parties continue to search for ways to optimize dialysis access. Government and payer initiatives to increase access to renal replacement therapies (RRTs), particularly peritoneal dialysis (PD) and hemodialysis (HD), may have meaningful impacts from clinical and health-economic perspectives; and despite similar clinical and humanistic outcomes between the two dialysis modalities, PD may be the more convenient and resource-conscious option. This review assessed country-specific PD-First/Favored policies and their associated background, implementation, and outcomes. It was found that barriers to policy-implementation are broadly associated with government policy, economics, provider or healthcare professional education, modality-related factors, and patient-related factors. Notably, the success of a given country's PD-Favored policy was inversely associated with the extent of HD infrastructure. It is hoped that this review will provide a foundation across countries to share lessons learned during the development and implementation of PD-First/Favored policies.

Can dialysis patients be accurately identified using healthcare claims data?

BACKGROUND: While health insurance claims data are often used to estimate the costs of renal replacement therapy in patients with end-stage renal disease (ESRD), the accuracy of methods used to identify patients receiving dialysis - especially peritoneal dialysis (PD) and hemodialysis (HD) - in these data is unknown. METHODS: The study population consisted of all persons aged 18 - 63 years in a large US integrated health plan with ESRD and dialysis-related billing codes (i.e., diagnosis, procedures) on healthcare encounters between January 1, 2005, and December 31, 2008. Using billing codes for all healthcare encounters within 30 days of each patient's first dialysis-related claim ("index encounter"), we attempted to designate each study subject as either a "PD patient" or "HD patient." Using alternative windows of ± 30 days, ± 90 days, and ± 180 days around the index encounter, we reviewed patients' medical records to determine the dialysis modality actually received. We calculated the positive predictive value (PPV) for each dialysis-related billing code, using information in patients' medical records as the "gold standard." RESULTS: We identified a total of 233 patients with evidence of ESRD and receipt of dialysis in healthcare claims data. Based on examination of billing codes, 43 and 173 study subjects were designated PD patients and HD patients, respectively (14 patients had evidence of PD and HD, and modality could not be ascertained for 31 patients). The PPV of codes used to identify PD patients was low based on a ± 30-day medical record review window (34.9%), and increased with use of ± 90-day and ± 180-day windows (both 67.4%). The PPV for codes used to identify HD patients was uniformly high - 86.7% based on ± 30-day review, 90.8% based on ± 90-day review, and 93.1% based on ± 180-day review. CONCLUSIONS: While HD patients could be accurately identified using billing codes in healthcare claims data, case identification was much more problematic for patients receiving PD.

Dialysis facility and patient characteristics associated with utilization of home dialysis.

BACKGROUND AND OBJECTIVES: Nonmedical factors influencing utilization of home dialysis at the facility level are poorly quantified. Home dialysis is comparably effective and safe but less expensive to society and Medicare than in-center hemodialysis. Elimination of modifiable practice variation unrelated to medical factors could contribute to improvements in patient outcomes and use of scarce resources. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Prevalent dialysis patient data by facility were collected from the 2007 ESRD Network's annual reports. Facility characteristic data were collected from Medicare's Dialysis Facility Compare file. A multivariate regression model was used to evaluate associations between the use of home dialysis and facility characteristics. RESULTS: The utilization of home dialysis was positively associated with facility size, percent patients employed full- or part-time, younger population, and years a facility was Medicare certified. Variables negatively associated include an increased number of hemodialysis patients per hemodialysis station, chain association, rural location, more densely populated zip code, a late dialysis work shift, and greater percent of black patients within a zip code. CONCLUSIONS: Improved understanding of factors affecting the frequency of use of home dialysis may help explain practice variations across the United States that result in an imbalanced use of medical resources within the ESRD population. In turn, this may improve the delivery of healthcare and extend the ability of an increasingly overburdened medical financing system to survive.

Cost comparison of peritoneal dialysis versus hemodialysis in end-stage renal disease.

OBJECTIVE: To compare healthcare utilization and costs in patients with end-stage renal disease (ESRD) beginning peritoneal dialysis (PD) or hemodialysis (HD). STUDY DESIGN: Retrospective cohort study. METHODS: Using a US health insurance database, we identified all patients with ESRD who began dialysis between January 1, 2004, and December 31, 2006. Patients were designated as PD patients or as HD patients based on first-noted treatment. Patients with less than 6 months of pretreatment data and those with less than 12 months of data following initiation of dialysis ("pretreatment" and "follow-up," respectively) were dropped from the study sample. The PD patients were matched to HD patients using propensity scoring to control for differences in pretreatment characteristics. Healthcare utilization and costs were then compared over 12 months between propensity-matched PD patients and HD patients using paired t tests and Wilcoxon signed rank tests for continuous variables and using Bowker and McNemar tests for categorical variables, as appropriate. RESULTS: A total of 463 patients met all study entrance criteria; 56 (12%) began treatment with PD, and 407 (88%) began treatment with HD. Fifty PD patients could be propensity matched to an equal number of HD patients. The HD patients were more than twice as likely as matched PD patients to be hospitalized over the subsequent 12 months (hazard ratio, 2.17; 95% confidence interval, 1.34-3.51; P <.01). Their median healthcare costs over the 12-month follow-up period were $43,510 higher ($173,507 vs $129,997 for PD patients, P = .03). CONCLUSIONS: Among patients with ESRD, PD patients are less likely than HD patients to be hospitalized in the year following initiation of dialysis. They also have significantly lower total healthcare costs.

Identification of patients receiving peritoneal dialysis using health insurance claims data.

OBJECTIVE: The aim of this analysis was to assess alternative methods of identification of patients treated with peritoneal dialysis (PD) in health care claims databases for possible use in future analyses of costs of this treatment modality. METHODS: Using a US health insurance claims database spanning January 1, 2004, to December 31, 2006, we identified all patients with renal failure who satisfied a case-finding algorithm for PD anticipated to be highly specific, but not necessarily sensitive-namely, > or =2 claims for PD-related physician services (algorithm 1). All claims from these patients were assessed to identify additional PD-related codes, from which 6 additional algorithms were developed, each of which focused on specific categories of billing codes (eg, diagnostic, procedural/service, equipment). Patient selection was then reimplemented using these alternative algorithms. Concordance between the various algorithms and the extent to which resulting samples were similar in terms of patient characteristics, health care resource utilization, and costs were assessed. RESULTS: We identified a total of 132,274 patients in the database with > or =1 claim for renal failure and valid enrollment data. Among these patients, a total of 2329 satisfied case-selection criteria for algorithm 1, and 4031 patients met criteria for at least 1 of the 7 algorithms for PD. The most sensitive algorithm identified 2859 patients who might have received PD; the least sensitive, 211. Concordance between algorithms was relatively poor. Patients identified using each algorithm were similar, however, with respect to mean age (45-50 years), sex (54%-56% male), and the prevalence of selected comorbidities. Annualized median health care costs were similar across the various algorithms (range, US $80,967-$118,668). CONCLUSIONS: Based on the results from this analysis, it seems that health care providers bill insurers for PD-related care using a variety of codes. Investigators using health insurance claims data for analyses of patients treated with PD need to take this into account.

The financial implications for Medicare of greater use of peritoneal dialysis.

BACKGROUND: Although annual per-person health care costs for patients with end-stage renal disease (ESRD) on in-center hemodialysis greatly exceed those for patients on peritoneal dialysis (PD), which is a home dialysis therapy, current use of PD remains low. In April 2008, the Centers for Medicare & Medicaid Services issued a new Dialysis Conditions of Coverage final rule underscoring its intent to promote use of home dialysis whenever appropriate. OBJECTIVES: The objectives of this paper were to provide context for the use of in-home versus in-center dialysis, to describe factors that influence patterns of dialysis utilization in the United States, and to explore the magnitude of the potential savings that might result from broader use of home dialysis therapies. METHODS: A 5-year budget-impact analysis was performed using data from the 2007 Annual Data Report of the United States Renal Data System. Scenarios were developed in which the PD share of total dialysis was varied to estimate the impact on total Medicare dialysis costs. This study took the perspective of Medicare, the main payer for dialysis in the United States. RESULTS: If the PD share of total dialysis were to decrease from the current 8% to 5%, Medicare spending for dialysis would increase by an additional $401 million over a 5-year period. Alternatively, if the PD share of total dialysis were to increase to 15%, Medicare could realize potential savings of >$1.1 billion over 5 years. CONCLUSIONS: Similar to the conclusion articulated in the Dialysis Conditions of Coverage final rule, increasing clinically appropriate use of PD would be associated with considerable savings to Medicare and to the taxpayers who fund Medicare. These savings could be used to offset part of the financial burden of ESRD care on Medicare and to help legislators meet ever-tightening budgetary constraints.