Impact of initial dialysis modality and modality switches on Medicare expenditures of end-stage renal disease patients

Background. The number of end-stage renal disease (ESRD) enrollees and Medicare expenditures have increased dramatically. Pathways and associated Medicare expenditures in ESRD treatment need to be examined to potentially improve the efficiency of care. Methods. This study examines the impact of initial dialysis modality choice and subsequent modality switches on Medicare expenditure in a 3-year period. The Dialysis Morbidity and Mortality Study Wave 2 data by the United States Renal Data System (USRDS) is used along with the USRDS Core CD and USRDS claims data. Results. A total of 3423 incident dialysis patients (approximately equal number of peritoneal dialysis and hemodialysis) were included in the analysis. Unadjusted average annual Medicare expenditure (in 2004 dollars) for peritoneal dialysis as first modality was $53,277 (95% CI $50,626-$55,927), and $72,189 (95% CI $67,513-$76,865) for hemodialysis. Compared to "hemodialysis, no switch" subgroup, "peritoneal dialysis, no switch" had a significantly lower annual expenditure ($44,111 vs. $72,185) (P < 0.001). "Peritoneal dialysis, with at least one switch" and "hemodialysis, with at least one switch" had a lower or similar annual expenditure of $66,639 and $72,335, respectively. After adjusting for patient characteristics, annual Medicare expenditure was still significantly lower for patients with peritoneal dialysis as the initial modality ($56,807 vs. $68,253) (P < 0.001). Similarly, compared to "hemdialysis, no switch" subgroup, "peritoneal dialysis, no switch" and "peritoneal dialysis, with at least one switch" had a significantly lower total expenditure. Further analysis showed that time-to-first switch also independently impacted total expenditure. Conclusion. Initial modality choice (peritoneal dialysis or hemodialysis) and subsequent modality switches had significant implications for Medicare expenditure on ESRD treatments.