Dissertations & Theses (Open Access)

Date of Award


Degree Name

Doctor of Philosophy (PhD)


Suja S Rajan

Second Advisor

Kevin Furman Erickson

Third Advisor

David R Lairson


In January 2011, the U.S. Centers for Medicare & Medicaid Services (CMS) implemented the expanded prospective payment system (PPS) for financing the management of end-stage renal disease (ESRD). Expanded PPS may not only change healthcare providers’ decisions about patient care by removing the financial incentives associated with the previous composite rate payment methodology, but also change the Medicare expenditures associated with various treatment patterns by using a constant base rate for all dialysis modalities. This study aimed to examine the effect of the expanded PPS on providers’ decisions on timing of dialysis initiation and ESA utilizations in ESRD patients as well as the association between different dialysis treatment patterns and Medicare expenditures. Incident ESRD patients were identified using the United States Renal Data System (USRDS) data between 2006 and 2016. We performed interrupted time-series analysis to examine the effect of the expanded PPS on timing of dialysis initiation and ESA utilizations in ESRD patients. We performed intention-to-treat analysis and as-treated analysis to examine the association between treatment pattern and cumulative 3-year Medicare expenditures of ESRD patients after expanded PPS implementation. The treatment pattern was characterized by initial dialysis modality type and subsequent modality changes. We found significant decrease in the odds of early dialysis initiation following expanded PPS implementation. We also found that the odds of using ESAs and the cumulative 6-month doses of ESAs in pre-and post-dialysis initiation periods decreased following expanded PPS implementation; the magnitude of decrease in ESA utilization in the post-dialysis initiation period was larger than that in the pre-dialysis initiation period after expanded PPS implementation. In addition, the study found that patients who initiated peritoneal dialysis (PD) and stayed on PD had lower cumulative 3-year Medicare expenditure compared with patients who initiated hemodialysis (HD) and stayed on it. However, PD patients who switched to HD had a significantly higher cumulative 3-year Medicare expenditure than those who initiated HD and stayed on it or switched to PD, regardless of when the switch to HD occurred during the first 3 years after dialysis initiation. Our findings suggest that 1) The 2011 expanded PPS reduced the odds of early dialysis initiation and dis-incentivized the volume and intensity of ESA utilization in the post-dialysis initiation period; and 2) After the implementation of expanded PPS, steady use of PD remains a better dialysis option than HD in terms of costs. However, patients who initiated PD and switched to HD may lose this economic advantage.