Bivariate functional patterns of lifetime medicare costs among ESRD patients

Abstract

In this work we study the lifetime Medicare spending patterns of patients with end-stage renal disease (ESRD). We extract the information of patients who started their ESRD services in 2007–2011 from the United States Renal Data System (USRDS). Patients are partitioned into three groups based on their kidney transplant status: 1-unwaitlisted and never transplanted, 2-waitlisted but never transplanted, and 3-waitlisted and then transplanted. To study their Medicare cost trajectories, we use a semiparametric regression model with both fixed and bivariate time-varying coefficients to compare groups 1 and 2 as well as a bivariate time-varying coefficient model with different starting times (time since the first ESRD service and time since the kidney transplant) to compare groups 2 and 3. In addition to demographics and other medical conditions, these regression models are conditional on the survival time, which ideally depict the lifetime Medicare spending patterns. For estimation we extend the profile weighted least squares (PWLS) estimator to longitudinal data for the first comparison and propose a two-stage estimating method for the second comparison. We use sandwich variance estimators to construct confidence intervals and validate inference procedures through simulations. Our analysis of the Medicare claims data reveals that waitlisting is associated with a lower daily medical cost at the beginning of ESRD service among waitlisted patients, which gradually increases over time. Averaging over lifespan, however, there is no difference between waitlisted and unwaitlisted groups. A kidney transplant, on the other hand, reduces the medical cost significantly after an initial spike.