Biomedical subjects

Erik C Roys

Publications and source records attributed to Erik C Roys.

5 recordsLinked to original sources

PubMed2006

Understanding the basic case-mix adjustment for the composite rate.

In April 2005, Medicare began adjusting payments to dialysis providers for composite-rate services for a limited set of patient characteristics, including age, body surface area, and low body mass index. We present analyses intended to help the end-stage renal disease community understand the empirical reasons behind the new composite-rate basic case-mix adjustment. The U-shaped relationship between age and composite-rate cost that is reflected in the basic case-mix adjustment has generated significant discussion within the end-stage renal disease community. Whereas greater costs among older patients are consistent with conventional wisdom, greater costs among younger patients are caused in part by more skipped sessions and a greater incidence of certain costly comorbidities. Longer treatment times for patients with a greater body surface area combined with the largely fixed cost structure of dialysis facilities explains much of the greater cost for larger patients. The basic case-mix adjustment reflects an initial and partial adjustment for the cost of providing composite-rate services.

Adult↗

PubMed2005

Economic impact of case-mix adjusting the dialysis composite rate.

The Medicare program reimburses dialysis providers a flat rate for a bundle of services that comprise the basic dialysis treatment. This payment system is being modified to incorporate case-mix adjustment for age and body size, which have been shown to influence dialysis costs. This study simulated the economic impact of the recently issued Medicare rule on case-mix adjustment by estimating the variation in payments across patients, facilities, and broad classes of facilities. Case-mix adjustment results in considerable patient-level variation in payments (dollar 12.99 SD in case-mix adjusted payments). The variation across dialysis facilities is smaller but still economically significant (dollar 3.77 SD). However, there was little evidence that particular classes of facilities (e.g., ownership, chain membership, size) will be substantially advantaged or disadvantaged by case-mix adjustment. There do seem to be modest changes in the regional distribution of payments.

Adolescent↗

PubMed2003

Is case-mix adjustment necessary for an expanded dialysis bundle?

Congress has required CMS to expand the Medicare outpatient prospective payment system (PPS) for dialysis services to include as many drugs and diagnostic procedures provided to end stage renal disease (ESRD) patients as possible. One important implementation question is whether dialysis facility case mix should be reflected in payment. We use fiscal year (FY) 2000 cost report and patient billing and clinical data to determine the relationship between costs and case mix, as represented by several patient demographic, diagnostic, and clinical characteristics. Results indicate considerable variability in costs and case mix across facilities and a significant and substantial relationship between case mix and facility cost, suggesting case mix payment adjustment may be important.

Adolescent↗

PubMed2002

Tailoring the initial vascular access for dialysis patients.

BACKGROUND: Creating a functioning initial arteriovenous (AV) access for aging and diabetic end-stage renal disease (ESRD) hemodialysis patients has been a challenge. METHODS: This study describes 748 consecutive primary AV access creations and their primary (unassisted) and secondary (assisted) access survival at a single center. Twenty-four percent of the patients had diabetes as their cause of ESRD and the average age was 59.6 years. No patient receiving an initial AV access required synthetic graft material. All received an AV fistula. Three types of fistulae were created and their distribution varied significantly for diabetic and non-diabetic patients (respective percentages): forearm AV fistula (24%, 62%), perforating vein fistula (PVF) at the elbow (48%, 21%) and non-PVF at the elbow (29%, 17%). RESULTS: Results of access survival for age groups <65 and 65+ years, male and female, diabetic and non-diabetic subgroups ranged from 51 to 75% for unassisted and from 75 to 96% for assisted two year access survival. PVF appeared to be advantageous over non-PVF access at the elbow. First intervention for peripheral steal syndrome was required at a rate of 7 and 0.6 per 100 patient-years at risk for diabetic and non-diabetic patients, respectively. The thrombosis rates per patient year of 0.03 for non-diabetics and 0.07 for diabetics are superior to previously published results for AV fistulae or for a combined AV fistula-AV graft approach. CONCLUSIONS: Potential explanations for these excellent results among elderly and diabetic patients include preoperative evaluation, exclusive use of native vessels, a variable surgical approach including PVF, and the experience of a single operator.

Age Factors↗

PubMed2002

Dialysis dose and body mass index are strongly associated with survival in hemodialysis patients.

Low dose of hemodialysis (HD) and small body size are independent risk factors for mortality. Recent changes in clinical practice, toward higher HD doses and use of more high-flux dialyzers, suggest the need to redetermine the dose level above which no benefit from higher dose can be observed. Data were analyzed from 45,967 HD patients starting end-stage renal disease (ESRD) therapy during April 1, 1997, through December 31, 1998. Data from Health Care Financing Administration (HCFA) billing records during months 10 to 15 of ESRD were used to classify each patient into one of five categories of HD dose by urea reduction ratio (URR) ranging from <60% to >75%. Cox regression models were used to calculate relative risk (RR) of mortality after adjustment for demographics, body mass index (BMI), and 18 comorbid conditions. Of the three body-size groups, the lowest BMI group had a 42% higher mortality risk than the highest BMI tertile. In each of three body-size groups by BMI, the RR was 17%, 17%, and 19% lower per 5% higher URR category among groups with small, medium, and large BMI, respectively (P < 0.0001 for each group). Patients treated with URR >75% had a substantially lower RR than patients treated with URR 70 to 75% (P < 0.005 each, for medium and small BMI groups). It is concluded that a higher dialysis dose, substantially above the Dialysis Outcomes Quality Initiative guidelines (URR >65%), is a strong predictor of lower patient mortality for patients in all body-size groups. Further reductions in mortality might be possible with increased HD dose.

Body Constitution↗