INDEX
A
Abandonment of patients, 58
Access to care
certificate of need and, 10, 158-163
defined, 335
dialysis patients, 135-164
donor organ supply and, 179-182
education/information and, 150-152
exclusion of individuals for medical reasons, 178
geographic variation in, 138-140, 160-162
and ineligibility for Medicare benefits, 6-7, 136-148
insurance coverage (private) and, 152-154, 172-173, 177-178, 330
magnitude of problem, 138
Medicare-eligible patients, 148-157
and payment sources other than Medicare, 140-146, 177-178
pediatric patients, 115, 149-150, 175, 176
preventive services, 156-157
rehabilitation services, 155-156
state regulations and, 158-163
transplants, 7-8, 167-185, 187
transportation and, 154-155
Activities of daily living, 335, 284
Advance directives, 56, 59-60, 335
Age
and acceptance for treatment, 8, 52-53
and diabetic kidney disease, 90, 93
and employment of ESRD patients, 155
ESRD patient trends, 27, 64, 65, 67-68, 70, 91, 100, 150, 216
and health insurance coverage, 152
and hypertension, 95
and hypertensive ESRD, 90, 95-98
and mortality rates, 72, 74, 76-78, 213
and treatment modality, 91, 92, 168
and transplants, 168, 175, 176
see also Elderly patients;
Pediatric patients
Agency for Health Care Policy and Research, QA responsibilities, 276, 287-288
AIDS, 53, 178, 179-180, 184, 252, 286
Albuminuria screening, 94
Alternative Reimbursement Method, 202-203
American Diabetes Association, 94-95
American Medical Association, 202
American Outpatient Services Corporation, 129
American Society of Artificial Internal Organs, 329
American Society of Nephrology, 329
American Society of Transplant Surgeons, 316
Anemia
clinical indicators of outcomes and process, 19, 281, 307-308
treatment of, 14, 25, 201, 226, 293-294, 305-308
see also Erythropoietin
Antihypertensives, 88, 142-143
Arkansas, Medicare eligibility status of ESRD patients, 138-139
Asians/Pacific Islanders with ESRD
gender differences in, 101
incidence and prevalence, 66-67, 70, 100, 103
Association for the Advancement of Medical Instrumentation, 228
Atherosclerotic disease, 53, 79, 80
B
Baxter Healthcare, 329
Baxter Laboratories, 229
Blacks with ESRD
health insurance coverage, 152
incidence and prevalence, 5, 66-68, 70, 85-86, 99-100, 103, 156
mortality rates, 74, 76, 78, 105
pediatric patients, 85-86, 115
preventive care for, 156
primary diagnosis, 68-69
transplant rejection, 104
treatment modalities, 104, 175, 176-177, 183
see also Race/ethnicity
Blood pressure, and renal disease, 99
Bone abnormalities, 86, 87-88, 149
C
Calcium/phosphorus metabolism controllers, 143
Cardiac disease, 53
Carpal tunnel syndrome, 319
Case mix
and composite rate, 252-253
defined, 336
in quality-of-life studies, 283, 284-285, 294-296, 319
reimbursement rate-setting and, 252-253, 284, 290
Catastrophic Health Insurance Act of 1988, 172
Catheter declotting, 238
Center hemodialysis, mortality rates, 77
Centers for Disease Control, QA responsibilities, 228, 276, 286
Cerebrovascular disease, 53, 79, 80
Certificate of need
and access to care, 10, 158-163
constraints on providers, 114
defined, 336
elimination of, 160
survey of programs, 26
Chronic heart insufficiency, 80
Chronic pulmonary disease, 53, 79, 80
Cirrhosis, 80
Clinishare, 129
Community Psychiatric Centers, 129
and acceptance for treatment, 8, 53
defined, 337
in measures of quality, 280
and mortality rates, 72, 80, 94
in pediatric populations, 86
and quality of life, 8
severity assessment, 285
Composite rate
1983 ESRD, 12, 213-217, 220, 243, 253
1986 reduction proposal, 243-244
audited costs contrasted with, 245-246
and case mix, 252-253
covered outpatient services, 15-16, 29, 193, 236-240
derivation of, 196-199;
see also Rate-setting process
exceptions and exemptions, 252-253
home dialysis supplies reimbursement, 25, 229
inflation/market basket adjustments, 252, 271
labor portion on, 254-255
and mortality, 12
and patient morbidity, 217
and quality of care, 213-217
rebasing and updating, 251-254
reported costs contrasted with, 247-248
and unit staffing levels and composition, 220-221
see also Reimbursement
Conditions of coverage for ESRD providers, 18, 288-290
Congressional charge to IOM, 3-4, 23-24, 62, 133, 212, 274
Connecticut, 158-162
Continuity of care
concerns of patients, 42-43
Continuous ambulatory peritoneal dialysis, 162, 199, 228-229, 279, 283, 284, 309, 319, 337
Continuous cycling peritoneal dialysis, 201, 337
Continuous quality improvement, 19, 276, 297-300
Corticosteroid therapy, 88
Cox proportional hazards model, 74, 319
Cox regression model, 77
Criteria screens, 253
Cushingoid facies, 88
Cyclosporine, 14, 143, 170, 172, 226, 230
D
Data systems
artifacts of, 73
National End-Stage Renal Disease Registry, 21, 25, 296, 321-324
provider, 309-311
see also Health Care Financing Administration;
Program Management and Medical Information System;
United Network for Organ Sharing;
United States Renal Data System
Dementia, 53
Demonstration project, 25, 155, 201
Department of Veterans Affairs, 29
data reported to HCFA, 318
dialysis program, 6, 63, 65, 139, 140, 146
ESRD expenditures, 33, 147, 148
financial problems of patients, 136
research in dialysis, 329
Diabetes mellitus, 5, 12, 102, 338
Diabetic ESRD patients, 28, 29
albuminuria screening, 94
employment of, 155-156
incidence and prevalence of ESRD, 29, 52, 63, 65, 66-68, 70, 93, 106
insulin-dependent, 93
mortality rates, 74-76, 78, 79, 81, 92, 94
non-insulin-dependent, 93-94, 101, 102
prevention, 94
protein intake, 94-95
quality of life, 283
racial differences, 68-70, 93-94, 102
risk factors, 94
transplants, 168
treatment of, 92-93
Diagnosis-related groups, 268, 270
Dialysis
access problems, 135-164
and anemia, 14, 25, 201, 226, 293-294, 305-308
appropriateness of, 53
characteristics of patients, 52
costs of, 6, 14, 29, 135, 168, 226, 228, 254-255
covered services/allowable costs, 237, 242, 256
defined, 338
demand for, 10
elements involved in use of, 278-279
equipment and supplies, 45, 226-229, 244, 252, 253, 286-287
hostile, abusive patients, 9, 58
infection control program, 286, 287
noncompliant, self-destructive patients, 9, 57-58
patient population increases, 111
price level and hospitalization rates and length of stay, 13
processes of care, 277-278
reimbursement rate-setting, 27
reuse of equipment and supplies, 45
state programs, 144
technicians, 13, 43, 161, 218-220, 222, 223, 230, 277, 290
treatment times, 12-14, 214, 215, 217, 227, 230, 232, 244, 311
withdrawal from, 53
see also Hemodialysis;
Inpatient dialysis;
Outpatient dialysis;
Peritoneal dialysis
Dialysis Clinic, Inc., 129, 152, 178, 216, 218, 224-225, 300, 309-310
Dialysis Management, Inc., 126
Dialysis treatment facilities
conditions of coverage, 288-289
cost reduction measures, 244-245
cost report data, 241
defined, 33-339
for-profit, 111
HCFA state surveys of, 19
number of Medicare-certified, 111
patient concerns about, 43
pediatric, 112
purchase prices of, 130
QA considerations and examples, 299-300, 309-311
response to economic constraints, 215-216, 225
rural, 112
staffing in, 13, 14, 43, 218-226, 230, 244-245, 290
utilization, 158-159
see also Outpatient dialysis
Dialyzers, 226-227, 228, 244, 252
Dietitians, 13, 219, 220-222, 225, 230, 277, 290
Do Not Resuscitate status, 56
Durable power of attorney for health care, 56, 57, 339
E
Education and training
and access to care, 150-152
of dialysis technicians, 223, 287
and employment of ESRD patients, 155
for organ donation, 143
of patients, 41, 44-46, 50, 150-152, 289
QA-related, 287
Elderly ESRD patients
causes of death, 92
growth in number of, 27, 29, 56-57, 89-90, 92, 106
incidence and prevalence of ESRD, 63, 90
mortality rates, 91
primary diagnosis, 90
treatment modality, 91, 92, 150, 175
see also Age
Employment, barriers to, 48-49, 50, 155-156, 171, 173
End-stage renal disease (ESRD)
causes of, 5
defined, 339
economic effects of, 47-49, 50, 330
patient experiences with, 40-47
race and, 5
End-stage renal disease patients
acceptance criteria, 8, 52-55, 63, 66
age trends, 27, 64, 65, 67-68, 70, 91, 100, 150, 216
autonomy model of rights, 41
complexity (case mix), 252-253
26, 27-28, 51-52, 65-69, 168, 174-178, 216, 256
conformance with treatment, 41, 42, 57-58, 80
counseling and self-help groups, 46
data sources and data files on, 317
effects of erythropoietin, 47, 50
employment problems, 48-49
experiences with renal failure, 40-47
family issues, 44
financial concerns and problems, 44, 47-49, 50, 150
incidence and prevalence of, 3, 5, 27, 30, 62-65, 70, 82
ineligible for Medicare benefits, 6, 7, 136-148
informed consent, 41
participation in care, 39, 276-277
by primary diagnosis, 64, 67-70
projections, 27-28, 30, 63, 66, 81-83, 90, 256
quality-of-life ratings, 8, 54
relationships with physicians and staff, 40-44, 49-50, 57-58, 151, 282
services important to, 46
types raising problems for providers, 9
see also Elderly ESRD patients;
Focus groups;
Pediatric ESRD patients
End-Stage Renal Disease program
cost control, 6
entitlement under Medicare, 3, 4, 7, 23, 35, 89, 135, 137
mortality in, 11-12, 69, 71-72
networks, 19, 24-25, 55-56, 276, 288, 291-293, 296-297, 319, 339
End-stage renal disease treatment
acceptance criteria, 8
cost-effectiveness studies, 21
duration and outcomes, 12-13, 214, 215, 217
limited-treatment plans, 56
modalities, see Dialysis;
Transplants/transplantation;
Treatment modality quality of care, 19;
see also Quality assessment and assurance
racial differences in, 103-104
technology, 26;
see also Innovations and technical change
time-limited trials, 56
withdrawal from, 9, 53-54, 55-57, 91
Epidemiology of kidney disease, 339
hypertensive, 96-98
diabetes, 63, 65, 66-68, 70, 93, 106
pediatric, 85-86
projections, 63, 66, 81-83, 90
research efforts, 20-21
see also Mortality
Erythropoietin, 281
clinical trials, 282, 294, 306
costs of, 201-202
effects of, 47, 50, 156, 306-307
injections per year, 239-240
and quality of life, 283-284, 294, 307-308, 319, 320
reimbursement policy, 25, 142-143, 193, 196, 201-202, 230, 239-240, 293, 295, 323
self-administration of, 25, 294
Ethical issues
access to treatment, 51
facility ownership by physicians, 129-130
initiation of treatment, 8-9, 53-54
patient acceptance criteria, 8, 52-55
transplants, 168
withdrawal from treatment, 9, 53-54, 55-57
Europe, survival of diabetic ESRD patients, 81
European Dialysis and Transplant Association, 79-80, 149-150
F
First-difference model, 12, 213-214
composition of, 39-40, 409-410
objective of, 39-40
see also End-stage renal disease patients
Food and Drug Administration, QA responsibilities, 229, 276, 286-287
G
Gastrointestinal disease, 80
Gender
and diabetic kidney disease, 68-70, 93
and employment of ESRD patients, 155
and hypertension, 95
and hypertensive ESRD, 68-70, 95-98
incidence and prevalence of ESRD, 66-70, 85, 101
Glomerulonephritis, 5
Glomerulonephritic ESRD, 5
gender differences, 69-70
incidence and prevalence of, 67, 68, 70
racial differences, 69-70, 102
Greenfield Health Systems Corporation, 129, 300, 310
Growth retardation, 86, 87, 88, 149
H
Health Care Financing Administration (HCFA)
administration of, 315
annual report on ESRD program, 316-317
Bureau of Data Management and Strategy, 293, 295, 315, 317
Bureau of Policy Development, 19, 293-294, 295
conditions of coverage for ESRD providers, 18, 288-290
coordination within, 295-296
data acquisition, analysis, and systems, 20, 69, 71, 231, 315-318;
see also Program Management and Medical Information System
Health Standards and Quality Bureau, 19, 151, 288, 291-293, 295
Office of Research and Demonstrations, 19, 293, 294-295, 295, 317
patient survival data, 69
position on social service requirements, 224
QA responsibilities, 11, 19, 276, 288-297
state surveys of dialysis facilities, 19, 110, 276, 288, 290-291, 316, 318
Health insurance (private)
and access to care, 152-154, 172-173, 177-178, 330
payment and/or qualification for, 48, 50, 154, 172-173
state payments into, 143
use by Medicare ineligibles, 136
Health Omnibus Programs Extension of 1988, 173
Health Systems Management, 129
Hemodialysis
defined, 340
home, 25
innovations in, 226-228
patient distribution, 5
see also Dialysis
Hemodialysis, Inc., 129
Hirsutism, 88
Hispanics with ESRD, 5
access to care, 157
diabetics, 93
gender differences in, 101
incidence and prevalence of, 99, 100, 102
non-Medicare dialysis patients, 139
Home hemodialysis
age and, 91
defined, 340
EPO administration, 202
paid aides for, 25
race and, 104
relationships with providers, 40
Home Intensive Care, Inc., 25, 129, 200-201
Hospital Corporation of America, 298
Hospitals
backup dialysis units, 251, 259, 336
organ donation protocols, 182
outpatient dialysis, 116-117, 119-121, 124, 125, 127, 128, 131, 159, 160
reimbursement of, 13, 29, 205-209
Hospitalization of dialysis patients reimbursement effects on, 216 -217, 230
reimbursement for, 12-13, 205-209
treatment time and, 217
trends, 319
Hypercreatinemia, 99
Hyperlipidemia, 99
Hyperphosphatemia, 310
Hypertension, 5
age and, 95
erythropoietin and, 307
relationship to hypertensive ESRD, 96
in United States, 95-96
Hypertension Detection and Follow-up Program, 98-99
Hypertensive cardiomegaly, 80
Hypertensive ESRD
and diabetic nephropathy, 94, 97
epidemiology of, 96-98
gender differences, 68-70, 95-98
incidence and prevalence of, 65-68, 70, 95-98, 106, 157
interventions, 98-99
mortality rates, 75-76, 78, 94, 96
racial differences, 68-70, 95-98, 101, 102
relationship to hypertension, 96
I
Illinois, Medicare eligibility status of ESRD patients, 138-139, 141
Immunosuppressive drugs, 168
Medicare eligibility limitations, 4, 7, 24, 171-172, 174
patient concerns about, 45
reimbursement for, 193
side-effects in pediatric patients, 88
see also Cyclosporine;
Imuran
Imuran, 143
Indian Health Service, 6, 103-104, 140, 143, 146, 147
Infection control program, 286
Innovations and technical change
clinical, 14
and composite rate, 253
dialysis research support, 229-220
equipment and supplies, 14, 226-228
hemodialysis, 226-228
labor substitution opportunities, 225
peritoneal dialysis, 228-229
reimbursement and, 13-14, 226-231
Inpatient dialysis, 29
age and, 91
capacity limits, 162
hospital reimbursement, 205-207
physician reimbursement, 208-209
reimbursement for, 205-209
J
Japan, ESRD mortality data, 79-80, 81
Joint Commission on Accreditation of Healthcare Organizations, 276
K
Kentucky Organ Donation Agency, 179
Kidney Care, 129
Kidney failure, see End-stage renal disease
Kidneys
acquisition costs, 191-192
supply of donors, 8, 87, 178-182
L
Licensed practical nurses, 13, 218-220, 290
Limited-treatment plans, 56
M
Maryland, Medicare eligibility status of ESRD patients, 138-139
Medicaid, see State Medicaid programs
Medical Case Review Procedures, 19, 292
Medical Device Amendments of 1976, 286
Medical Outcomes Study, 277, 278, 282, 285
Medical records review, 292-293
Medical review boards, 291-292
Medical Treatment Effectiveness Program, 288
Medicare
Automated Data Retrieval System, 35
conditions of participation, 150, 182
cost data timeliness, 240-241, 271
data sources and data files of ESRD patients and providers, 317
data systems adequacy, 324-325
defined, 341
eligibility for ESRD program, 3, 4, 7, 23, 149, 166, 339
expenditures for ESRD beneficiaries, 6, 28-33, 166, 168
expenses not covered by, 152
Fee Schedule, 18, 204, 255-256, 259
Hospital Insurance Trust Fund, 148
Part A Cost Principles, 241-242, 247, 342
recertification based on organ donor standard, 182
as secondary payer, 153-154, 193, 215, 260, 330
Supplemental Medical Insurance Trust Fund, 148
injections per year, 239-240, 254
reimbursement for, 25, 142-143, 193, 196, 201-202, 239
transplant-related, 144, 168, 170, 171-172, 174;
see also Immuno-suppressive drugs
see also specific drugs
Michigan Kidney Registry, 77, 143
Minnesota Regional Kidney Disease Program, 77, 79, 80, 129
Minority patients, see Race/ethnicity; and specific minorities
Models/modeling
Bailey-Makeham, 391
continuous quality improvement, 297-300
exponential, 390
logistic regression for probability of death, 388-391
parametric, 390-391
Poisson regression for death rates, 383-386
prescription dialysis, 253
price-level, 12, 13, 213-214, 217
regression models, 381-386
reimbursement effects, 12, 13, 213-214, 217
statistical methods for ESRD mortality data, 383-389
survival analysis, 372-373
Weibull, 390-391
Monthly capitation payment, 18, 202-204, 208, 255-256, 259, 341
Morbidity
defined, 341-342
and dialysis treatment time, 14
measures of, 12-13
as outcome measure, 279
see also Hospitalization
Mortality
analyses, 71, 295-296, 330-331;
see also Statistical methods for ESRD mortality data;
Survival analysis
defined, 342
and dialysis treatment times, 12, 14
in ESRD program, 11-12, 69, 71-72
factors causing changes in, 71, 72, 80
international comparisons, 79-81, 395-399
as outcome measure, 12, 214-216, 279, 294
private insurance and, 152
source of data, 69
state and regional data, 77, 79
subgroup, 74-78, 88, 91, 94, 103-104
treatment modality and, 104, 320
treatment time and, 12-13, 214, 215, 221, 222
Multivitamin compounds, 143
N
Navajo Indians, 101
National Center for Health Services Research, 288
National End-Stage Renal Disease Registry, 21, 25, 296, 321-324, 318
National Health and Nutrition Examination Survey (II), 95, 102
National Institute of Allergy and Infectious Diseases, 287
National Institute of Diabetes and Digestive and Kidney Diseases, 20-21, 229, 285, 287, 296, 318-323, 330
Artificial Kidney/Chronic Uremia program, 227, 229, 287, 329
National Institutes of Health
QA responsibilities, 287
National Kidney and Urologic Diseases Advisory Board, 328-329
National Kidney Foundation, Council of Nephrology Social Workers, 223-224
National Medical Care, Inc., 126, 129, 300, 310-311
National Medical Enterprises-Medical Ambulatory Care, 129
National Medical Review Criteria Screens, 19, 292
National Organ Transplant Act of 1986, 9, 25, 111, 170-171, 173, 182, 320
National Task Force on Organ Transplantation, 173, 175
Native Americans with ESRD
gender differences, 101
incidence and prevalence of, 66-67, 70, 99-100, 103
non-Medicare dialysis patients, 139, 143, 146
outcomes research, 321
primary diagnosis, 68, 93, 101
see also specific tribes
Neomedica Dialysis Centers, Inc., 129
Neurologic impairment, 53, 86, 88
New Mexico, Medicare eligibility status of ESRD patients, 138-139
New West Dialysis, 129
North American Pediatric Renal Transplant Cooperative Study, 149
North Central Dialysis Centers, 218-219, 220
Northwest Kidney Center, 129
Nursing/nurses
quality assurance by, 277, 282
reimbursement effects on, 222-223, 230
requirements limiting capacity, 161
shortages, 43
staffing of dialysis units, 218-223
standards for, 289-290
Nutrition, parenteral, 238
O
Obesity, 88
Omnibus Budget Reconciliation Act of 1981, 193, 195, 215, 233, 249
Omnibus Budget Reconciliation Act of 1985, 291
Omnibus Budget Reconciliation Act of 1986
data collection and analysis mandate, 21, 25, 296, 318, 321-323
ESRD network reorganization, 24-25, 291-292
quality and appropriateness of patient care, 19
reimbursement policy, 197, 201, 231-232, 251
transplant provisions, 172, 173
Omnibus Budget Reconciliation Act of 1987
charge to IOM, 3-4, 23-24, 133, 135, 212, 274, 283
composite dialysis rates, 251
Omnibus Budget Reconciliation Act of 1989
creation of AHCPR, 287-288
reimbursement policy, 25, 199, 204, 251
Omnibus Budget Reconciliation Act of 1990
advance directives, 59
demonstration project, 155, 201
EPO policy, 202
OPO performance standards, 182
reimbursement policy, 25, 153, 193, 198-199
Organ donation, 143, 184, 191-192
and access to care, 179-182
Organ Procurement and Transplantation Network, 25, 171, 174, 182, 320
Organ procurement organizations, 9, 111, 114
grant assistance to, 173
reimbursement of, 192
staffing considerations, 183
Outcomes
defined, 342
measures, 12, 19, 216, 279-280, 294, 307;
see also Morbidity;
Mortality
research, 288
of transplants, 5, 167, 168, 170, 172, 174, 176
Outpatient dialysis
advance directives legislation applied to, 59-60
chains, 126, 129, 131, 243, 258
cost report audits, 241, 245-246, 262-267
costs per treatment, 249-250, 296
covered services, 15-16, 29, 236-240
facilities, 10, 112-114, 116-118, 119-122, 130, 193-202, 244-255
hospital backup units, 251
hospital-based providers, 116-117, 119-121, 124, 125, 127, 128, 131, 159, 160, 195, 196, 218, 221-222, 245-250, 257
independent providers, 117-119, 121, 124, 126-128, 131, 159, 160, 195, 196, 198, 218, 220-222, 245-250
not-for-profit providers, 119-124, 127-129
ownership of facilities, 126, 129-130, 251, 257
patient numbers, 116-117, 118-119, 120-122, 125
physician reimbursement, 202-205, 255-256
rate-setting process, 240-244
reimbursement for, 6, 11, 13, 15-18, 193-205, 236-260
sampling of units, 241
stations/size, 116-118, 120-129, 131
structural changes in provider community, 116-130
utilization rate, 116-117, 118-119, 131, 159-160, 162
see also Home hemodialysis
P
Parathyroid gland overactivity, 88
Patient
functional and health status, 279-283, 284
see also End-stage renal disease patients
Pediatric ESRD patients, 59
access to care, 115, 149-150, 175, 176
acne, 88
characteristics of population, 85-86
clinical trials of pharmaceuticals, 89
comorbidities, 86
health status assessment, 282
incidence and prevalence of, 85-86
ineligible for Medicare, 149
pubertal development delays, 86, 88
quality-of-life factors, 86, 149, 150
special problems and needs of, 85, 88-89, 106, 149-150, 251, 253, 259, 319
transplantation in, 86-87, 149, 175, 176
Peripheral vascular disease, 53, 79, 80
age and, 91
innovations in, 228-229
patient distribution, 5
race and, 104
Peritonitis, 319
Persistent vegetative state, 53
Physicians and other health care professionals
characteristics, 277
education about ethical issues, 56
education of patients, 44-45, 151
monthly capitation payment, 18, 202-204, 208, 255-256, 259, 341
ownership of treatment facilities, 129-130, 257
pediatric specialists, 89
quality assurance by, 276
reimbursement of, 192-193, 202-204, 208-209, 255-256
relationships with patients, 40-44, 49-50, 57-58, 151, 282
supplier services, 29
Poisson regression, 74
Polycystic disease, 75
Prescription drugs, see Medications; and specific drugs
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 53
Prevention of ESRD, 156-157, 329-330
Price-level model, 12, 13, 213-214, 217
Primary diagnosis of ESRD
among blacks, 68-69
distribution of patients by, 64, 67-70
among elderly patients, 90
among Native Americans, 68, 93, 101
survival analysis and, 364-365
see also Diabetic ESRD patients;
Glomerulonephritic ESRD patients;
Hypertensive ESRD patients
Processes of care, 19, 277-279, 281, 307-308
Professional Standards Review Organizations, 276, 288, 343
Program Management and Medical Information System, 62, 296, 315-318, 343
Prospective Payment Assessment Commission, 17, 18, 344, 241, 244
rate updating, 251, 258, 259, 260
Prospective Payment System, 215, 237, 343-344
inpatient hospital, 193-194, 205
Providers
certificate-of-need constraints on, 114
chains, 126, 129, 131, 243, 257, 310-311
characteristics, 277
conditions of coverage, 18
data sources and data files on, 317
demand for, 113
defined, 131
kidney transplant centers, 114-115
outpatient dialysis facilities, 10, 112-114
pediatric facilities, 115-116
response to economic constraints, 215-216
size of facilities, 113, 114, 115
staff/patient ratios, 43
structural changes in community, 9-10, 110-131, 116-130, 242
utilization of, 113
see also Dialysis treatment units;
Outpatient dialysis
Proximate clinical indicators, 279, 280-281, 305-308
Public Health Service
Bureau of Quality Assurance, 315
dialysis patients, 65
Public Health Service Act, 25, 171
Public hearings, 26-27, 218, 226, 242, 244, 245, 403-404
Q
Quality assessment and assurance (QA)
case mix and severity adjustments, 283, 284-285, 294-296, 319
conditions of coverage for ESRD providers, 18, 288-290
continuous quality improvement, 19, 276, 297-300
data needs, 296-297
defined, 344
in dialyzer reuse, 228
elements of ESRD QA function within Medicare, 18
federal responsibilities for, 276, 285-297;
see also specific agencies and authorities
functional-and health-status assessments, 281-283, 284, 294-295, 330-331
infection control program, 286
internal systems, 276
Medical Case Review Procedures, 19
medical review boards, 291-292
National Medical Review Criteria Screens, 19
obstacles, 274-275
patient satisfaction and, 283
principles of, 275-277
process of care and, 277-279, 280
proximate clinical indicators, 280-281, 305-308
purposes of, 275-276
quality of life and, 283-284
and rate-setting, 258
state surveys of dialysis facilities, 19, 110, 290-291
Quality of care, 17
certificate of need and, 10, 162
composite rate and, 213-217
cost of treatment and, 19, 244
measures of, 12-13, 19, 218, 279-280, 288
and provider community structure, 130-131, 257
reimbursement and, 11-18, 212-233, 256-257, 268-269, 272
standards of care, 237-238, 268-269, 280
treatment time and, 221
treatment unit staffing and, 43, 218-225
Quality of life
comorbidities and, 8
erythropoietin and, 283-284, 294, 307-308, 319
life-sustaining treatment and, 53
of pediatric patients, 86, 149
research, 294
R
Race/ethnicity
and age of ESRD patients, 100
and diabetic ESRD, 68-70, 93-94, 101, 102
and eligibility for Medicare ESRD program, 139-140
and ESRD incidence and prevalence, 5, 66-70, 85-86, 93, 99-103, 106, 157, 319
and glomerulonephritic ESRD, 101, 102
and hypertension, 95
and hypertensive ESRD, 68-70, 95-98, 101, 102
and mortality rates, 103-104
and primary diagnosis leading to ESRD, 67-70, 101
and risk of ESRD, 99
and treatment modality, 103-105, 176-177
see also Asian Americans;
Blacks;
Hispanics;
Native Americans
Rate-setting process
conflicts between HCFA and ESRD providers in, 243
cost data timeliness, 240-244, 271
cost-per-treatment calculation, 243-244
defined, 344
dissenting view of, 268-273
generally accepted accounting principles in, 242
goals of, 236
Medicare Part A cost principles in, 241-243, 247, 256
procedural issues, 243
public hearings on, 27, 242, 244, 245
and quality assessment and assurance, 251, 258, 290
sampling versus universe, 241, 262-267
Recommendations
access to treatment, 4, 7-8, 24
advance directives, 59
advisory group of nephrology professionals and experts, 20, 301
certificate of need, 11, 162-163
composite rate, 258-259
continuing education in medical ethics and health law, 9, 59
data systems, 19, 20-21, 301, 325-326
entitlement to ESRD treatment, 4, 7, 89, 148
funding considerations, 3, 24, 173
HCFA state survey system, 19, 301
kidney donation, 8, 183, 184, 326
immunosuppressive drug coverage, 8, 173
initiation of treatment, 9, 59
management of ESRD program, 4, 24
Medicare secondary-payer provision, 154
monitoring organizational changes in provider community, 10, 131
National End-Stage Renal Disease Registry, 21, 326
patient acceptance criteria, 9, 59
patient education, 152
quality assurance and assessment, 19-20, 259, 301-302, 326
reimbursement policies for dialysis facilities, 17-18, 19, 257, 258 -259, 301
transplant eligibility limits, 7-8, 173
United States Renal Data System, 21, 326
withdrawal from treatment, 59
Registered nurses, 13, 218-223, 289
Regulations
ESRD network medical review boards, 291-292
interim, of 1983, 227-228
see also Certificate of need;
State regulations
Rehabilitation
reimbursement for physical therapy, 239
Reimbursement
and access to care, 161
Alternative Reimbursement Method, 202-203
appropriateness screens, 291
assessing the effects of, 12, 213, 214-215
case mix and, 252-253, 284, 290
and clinical research, 329
current policy, 198-199
exceptions and exemptions, 194, 199-200, 252-253
facility/center, 191-192, 192-202, 244-255
and hospitalization, 216-217, 230
historical overview, 193-198
home dialysis, 25, 196, 199, 200-201, 202-203, 229
and innovation, 13-14, 226-231, 256
inpatient dialysis services, 205-209
level-of-payment issues, 244-249
for medications, 25, 142-143, 193, 196, 201-202, 230, 239-240, 293 -295
monthly capitation payment, 202-204, 208
and mortality, 12, 14, 212-216, 230
and patient characteristics, 207
of physicians, 192-192, 202-205, 208-209, 255-256
and quality of care, 11-18, 212-233, 247, 249, 256-257, 272
retrospective, cost-based, 242
staffing in treatment units and, 13, 14, 218-225, 230, 247, 290
transplant services, 191-193
see also Composite rate;
Rate-setting process
REN Corporation-USA, 129
Renal biopsy, 319
Renal Physicians Association, 323
Renal Treatment Centers Corporation, 129
Research
clinical, 20, 229, 282, 328, 329
dialysis, 229-230
epidemiologic, 21-22, 294, 296, 316, 318, 322-323, 330
on ethical issues, 59
health services, 22, 287-288, 324, 328, 331
mortality, 319, 330-331, 398-399
outcomes and effectiveness, 288, 319, 321, 331
preventive, 20
treatment modality effectiveness, 284, 320, 329-330
S
Salick Health Care, 129
San Antonio Heart Study, 157
Satellite Dialysis, 129
Self-help groups, 46
Sickness Impact Profile, 284, 307
Social Security Administration, Bureau of Health Insurance, 315
Social Security Amendments of 1972, 3, 6, 23, 133, 135, 170
Social Security Amendments of 1973, 137
Social Security Amendments of 1978, 195
Social Security disability regulations, 48, 50, 155, 171
Social workers, 13, 218-221, 222-225, 230, 290, 277
Southeast Organ Procurement Foundation, 174, 320
State kidney programs, 143-147
State Medicaid programs
benefits of, 6-7, 142, 146, 155
defined, 341
dual eligibles, 142
expenditures for ESRD patients, 140, 142
reimbursement levels and policy, 142
use by ESRD patients, 136, 140, 148
State regulations, and access to care, 158-163
Statistical methods for ESRD mortality data
Bailey-Makeham model, 391
comparative parameters, 380-383
Cox models for relative rates and survival functions, 386-388
death proportions, 376-377, 386-388
death rates, 377-379, 381-388, 393-394
descriptive parameters for one group, 376-380
expected lifetimes, 379-380
exponential model, 390
frailty, 392
institutional characteristics, 394
logistic regression for probability of death, 388-391
models and methods, 383-389
parametric models, 390-391
Poisson regression for death rates, 383-386
prevalent versus incident cohort analyses, 391-392
regression models, 381-386
sampling from risk set, 380-391
standardization (internal and external), 394-395
survival curves, 379, 382-383, 386-388
treatment modality, 393
Weibull model, 390-391
Survival analysis
adjustment for patient characteristics, 364-375
age adjustments, 358-359, 365, 397-398
biased comparisons, 358-359
comparison group, 357
constraints on adjustment process, 374-375
counts of patients, accuracy of, 363-364
data currently available for, 364-367
data unavailable or difficult to evaluate, 368-370
diagnosis and, 364-365
error (types I and II) issues, 363
etiology in, 396-397
examples of, 356-364
inappropriate comparison group, 358-359
gender in, 367
general issues in, 355-364
international comparisons, 79-81, 395-399
limitations of, 395-398
medical history, 368-369
modeling, 372-373
multivariable methods, 370-374
overview of, 355-356
parameters for mortality summaries, choice of, 362-363
patient follow-up, 398
population identification, 356-357
projections and extrapolations, 363
provider versus patient, 361-362
race in, 367
random variation in, 360-361
research needs, 398-399
significant versus important differences, 361
social support systems, 369-370
spurious differences in, 358
standard errors for population data, 359-360
stratification, 371-372
time in multiple measures, 367
treatment methods, 365-366
treatment modality, 368
unobserved factors, 359
variables exerting simultaneous effects, 374
withdrawal rates, 398
year of first treatment, 365-366
years of treatment, 366-367
see also Mortality;
Statistical methods for ESRD mortality data
Swedish dialysis centers, 80
T
Tax Equity and Fiscal Responsibility Act of 1982, 137, 345-346
Technicians, see Dialysis technicians
Texas Kidney Health Program, 102, 143
Tidewater Nephrology Associates, 129
Time-limited trials, 56
Training, see Education and training
Transplant Amendments Act of 1990, 173, 177, 184, 330
Transplant recipients
access restrictions, 7-8, 167-185, 187
characteristics of patient population, 5, 26, 91, 168, 174-178
compliance with drug regimens, 172
mortality rates, 75, 77, 82, 87
outcomes, 5, 167, 168, 170, 172, 174, 176
pediatric, 86-87, 149, 175, 176
projections, 82
racial differences in, 104-105, 176-177
rehabilitation services, 155
Transplants/transplantation
access to kidneys, 26, 87, 150, 167, 170, 173-178
from cadaver donors, 5, 75, 77, 82, 87, 104, 105, 114, 168-170, 175, 176, 182, 336
conditions of coverage, 288-289
cost-effectiveness of, 168
costs of, 6, 29, 115, 135, 168, 192
covered services, 237
demand for kidneys, 8, 167, 170
distribution of, 173-178
facilities/centers, 9, 111, 114-115, 191-192, 346
HLA matching, 104, 174, 175, 176, 177, 179, 319, 321
from living related donors, 5, 82, 87, 168-170, 175, 176, 192, 340, 284
media coverage of, 181-182
Medicare eligibility limitations, 4, 5, 24, 171
medications, 144, 168, 170, 171-172, 174;
see also Immunosuppressive drugs;
and specific medications
number of procedures, 5, 111, 114, 168-169, 171, 179
parent-child, 319
patient information about, 151
point scoring system, 176-177
reimbursement for, 191-193
rejection of grafts, 40, 88, 104, 105, 168, 284
state programs for, 144
supply of donor organs, 179-183
survival of grafts, 168, 170, 176
waiting lists, 40, 170, 171, 175-176, 192, 321
workup procedures, 143
Transportation
and access to care, 154-155
financial assistance for, 143-144, 150
distribution of patients by, 5
effectiveness research, 284, 320, 329-330
for elderly patients, 91, 92, 150, 175
race/ethnicity and, 103-105, 176-177
in statistical analyses, 368, 393
see also Dialysis;
Transplants/ transplantation
U
United Network for Organ Sharing, 174, 320-321
United States Renal Data System, 20, 21, 25, 62, 296, 318-320
mortality analyses, 69, 71, 323
Scientific Advisory Committee, 285, 323
Utilization and Quality Control Peer Review Organizations, 276, 288
Urokinase, 238
V
Vivra, Inc., 129
W
W.R. Grace, Inc., 129
West Suburban Kidney Centers, 129
Z
Zuni Indians, 102
