Early trends from the Study to Evaluate the Prospective Payment System Impact on Small Dialysis Organizations (STEPPS)

Am J Kidney Dis. 2013 Jun;61(6):947-56. doi: 10.1053/j.ajkd.2012.11.040. Epub 2013 Jan 15.


Background: Launched in January 2011, the prospective payment system (PPS) for the US Medicare End-Stage Renal Disease Program bundled payment for services previously reimbursed independently. Small dialysis organizations may be particularly susceptible to the financial implications of the PPS. The ongoing Study to Evaluate the Prospective Payment System Impact on Small Dialysis Organizations (STEPPS) was designed to describe trends in care and outcomes over the period of PPS implementation. This report details early results between October 2010 and June 2011.

Study design: Prospective observational cohort study of patients from a sample of 51 small dialysis organizations.

Setting & participants: 1,873 adult hemodialysis and peritoneal dialysis patients.

Outcomes: Secular trends in processes of care, anemia, metabolic bone disease management, and red blood cell transfusions.

Measurements: Facility-level data are collected quarterly. Patient characteristics were collected at enrollment and scheduled intervals thereafter. Clinical outcomes are collected on an ongoing basis.

Results: Over time, no significant changes were observed in patient to staff ratios. There was a temporal trend toward greater use of peritoneal dialysis (from 2.4% to 3.6%; P = 0.09). Use of cinacalcet, phosphate binders, and oral vitamin D increased; intravenous (IV) vitamin D use decreased (P for trend for all <0.001). Parathyroid hormone levels increased (from 273 to 324 pg/dL; P < 0.001). Erythropoiesis-stimulating agent doses decreased (P < 0.001 for IV epoetin alfa and IV darbepoetin alfa), particularly high doses. Mean hemoglobin levels decreased (P < 0.001), the percentage of patients with hemoglobin levels <10 g/dL increased (from 12.7% to 16.8%), and transfusion rates increased (from 14.3 to 19.6/100 person-years; P = 0.1). Changes in anemia management were more pronounced for African American patients.

Limitations: Limited data were available for the prebundle period. Secular trends may be subject to the ecologic fallacy and are not causal in nature.

Conclusions: In the period after PPS implementation, IV vitamin D use decreased, use of oral therapies for metabolic bone disease increased, erythropoiesis-stimulating agent use and hemoglobin levels decreased, and transfusion rates increased numerically.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Ambulatory Care Facilities / economics*
  • Anemia / drug therapy
  • Anemia / economics
  • Bone Density Conservation Agents / economics
  • Bone Density Conservation Agents / therapeutic use
  • Chronic Kidney Disease-Mineral and Bone Disorder / drug therapy
  • Chronic Kidney Disease-Mineral and Bone Disorder / economics
  • Cohort Studies
  • Erythrocyte Transfusion / economics
  • Erythrocyte Transfusion / statistics & numerical data
  • Female
  • Hematinics / economics
  • Hematinics / therapeutic use
  • Hemodialysis, Home / economics
  • Humans
  • Kidney Failure, Chronic / economics*
  • Male
  • Medicare / economics*
  • Middle Aged
  • Peritoneal Dialysis / economics
  • Peritoneal Dialysis / trends
  • Prospective Payment System / economics*
  • Prospective Payment System / trends
  • Prospective Studies
  • Renal Dialysis / economics*
  • Renal Dialysis / trends
  • United States
  • Young Adult


  • Bone Density Conservation Agents
  • Hematinics