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Principal Investigator: RICHARD A HIRTH
Organization: UNIVERSITY OF MICHIGAN AT ANN ARBOR
Fiscal Year: 2024
Award: $633,610
Funding agency: National Institute of Diabetes and Digestive and Kidney Diseases
PROJECT SUMMARY
The end stage renal disease (ESRD) population on dialysis is a longstanding challenge to manage. This
stems from high health care needs, and comorbidities, with mortality rates 10-fold greater than age-
matched controls and costs totaling 7% of Medicare’s budget. In contrast to peer countries, nearly 90% of
dialysis in the United States is performed in-center, at a dialysis facility. The reasons for this are often not
clinical, but related to financial investments in dialysis facilities, and the lower level of comfort by
nephrologists for home dialysis modalities. Many believe that increased use of home dialysis will
substantially improve care of the chronic dialysis population, given theoretical physiological advantages
(gentler and more continuous), and associations with better survival and lower health care costs.
However, the evidence comparing home versus in-center dialysis remains highly controversial given the
paucity of controlled clinical trials. Most observational comparisons are plagued by potential issues of
selection. Nevertheless, the Center for Medicare & Medicaid Innovation moved forward with the ESRD
Treatment Choices (ETC) Model in January 2021, providing robust financial incentives for dialysis centers
and nephrologists in randomly selected hospital referral regions to shift dialysis care delivery from the
facility to the patient home or to transplantation. Given severe constraints on organ availability for
transplantation, this is expected to lead to rapid increases in use of home dialysis. With mandatory and
random selection of model participants, there is an unprecedented opportunity to develop less biased
assessments of the relative merits of home versus in-center dialysis. First, preservation of residual kidney
function and continuous dialysis with home modalities has been proposed to better control uremia and
volume overload, conferring a survival benefit and reduced overall healthcare utilization. Second, there are
potential trade-offs with use of in-center versus home dialysis that can affect the care of comorbidities that
commonly afflict dialysis patients. For example, home modalities may better control heart failure, yet more
frequent medical contacts with providers with in-center dialysis may allow early attention to developing
issues that can avert acute exacerbations. Third, populations at high social risk (e.g., patients of Black
race, dual Medicare-Medicaid eligibles) have lower access to home dialysis, often justified on the basis of
poor housing quality and unstable living conditions. It is therefore particularly important to understand
whether such patients will realize a net benefit from home dialysis. Leveraging the ETC model’s quasi-
experimental design we propose a study with these Aims: 1) To compare overall survival and healthcare
spending between ESRD patients on home versus in-center dialysis; 2) To compare outcomes of care for
specific comorbidities between ESRD patients on home versus in-center dialysis; 3) To compare clinical
outcomes in ESRD patients on home versus in-center dialysis among populations at high social risk.
Terms: <Acute><Affect><Age><American><Attention><Black><Black race><Blood Circulation><Bloodstream><Budgets><Cardiac Failure Congestive><Caring><Chronic><Chronic Care><Clinical><Congestive Heart Failure><Controlled Clinical Trials><Country><Data><Death Rate><Diabetes Mellitus><Dialysis><Dialysis patients><Dialysis procedure><Disparity population><ESRD><Educational Models><End stage renal failure><End-Stage Kidney Disease><End-Stage Renal Disease><Ensure><Ethnic Origin><Ethnicity><Goals><Health><Health Benefit><Health Care Costs><Health Care Utilization><Health Costs><Health Insurance for Aged and Disabled, Title 18><Health Insurance for Disabled Title 18><Healthcare><Healthcare Costs><Heart Decompensation><Heart failure><Hemodialyses><Hemodialysis><Heterogeneity><Hispanic><Home><Home Hemodialyses><Home Hemodialysis><Home Renal Dialysis><Hospital Referrals><Housing><Infection><Instructional Models><Investments><Kidney><Kidney Grafting><Kidney Transplantation><Kidney Transplants><Kidney Urinary System><Life><Low income><Measures><Medicaid eligibility><Medical><Medicare><Medicare/Medicaid><Modality><Modeling><Organ><Outcome><Participant><Patients><Peritoneal Dialysis><Peritonitis><Physiologic><Physiological><Population><Procedures><Provider><Quasi-experiment><Quasi-experimental analysis><Quasi-experimental approach><Quasi-experimental design><Quasi-experimental methods><Quasi-experimental research><Quasi-experimental study><Quasi-experimental technique><Random Allocation><Random Selection><Renal Grafting><Renal Transplantation><Renal Transplants><Renal function><Research Resources><Residual><Residual state><Resources><Risk><Title 18><Transplantation><Uncertainty><United States><Uremia><ages><black patient><cardiac failure><care delivery><care outcomes><chronic heart failure><co-morbid><co-morbidity><comorbidity><cost><diabetes><dialysis therapy><disadvantaged group><disadvantaged individual><disadvantaged people><disadvantaged population><disadvantaged subgroup><disparities across groups><disparity across subgroups><disparity among groups><disparity among subgroups><disparity between groups><disparity between subgroups><doubt><educational methods><educational practices><educational principles><financial incentive><financial reward><group disparity><group inequality><group inequity><health care><health care outcomes><health care service use><health care service utilization><health insurance for disabled><healthcare outcomes><healthcare service use><healthcare service utilization><healthcare utilization><homes><hospital utilization><improved><inequalities among populations><inequalities between populations><inequalities in populations><inequality across populations><inequality among groups><inequality between groups><inequality in groups><inequities among populations><inequities between populations><inequities in populations><inequity across groups><inequity across populations><inequity between groups><inequity in groups><innovate><innovation><innovative><kidney function><kidney tx><monetary incentive><mortality rate><mortality ratio><patient population><patient subclass><patient subcluster><patient subgroups><patient subpopulations><patient subsets><patient subtypes><peer><population inequality><population inequity><preservation><renal><social><stem><subgroup disparity><time use><transplant><treatment choice><unequal group><unequal population><uremia of renal origin>