The major features of ESRD management in France include the predominance of hemodialysis and the resulting competition for dialysis stations. In 2003, the prevalence of ESRD in France was 0.087%. Of the 52,000 ESRD patients, 30,882 were receiving dialysis and 21,233 had functioning renal transplants. The annual expenditure per ESRD patient in 2003 was estimated at euro40,975. Autodialysis, at euro49,133 per patient per year, was much less expensive than dialyzing in-center at either a public or private facility (euro111,006 and euro75,125, respectively). Transplant activity in France has rapidly increased in recent years, reaching 22 donors per million population in 2005.

Many health care providers and policy makers believe that health care financing systems fail to reward high-quality care. In recent years, federal and private payers have begun to promote pay for performance, or value-based purchasing, initiatives to raise the quality of care. This report describes conceptual issues in the design and implementation of pay for performance for chronic kidney disease and ESRD care. It also considers the implications of recent ESRD payment policy changes on the broader goals of pay for performance. Congressionally mandated bundle payment demonstration for dialysis, newly implemented case-mix adjustment of the composite rate, and G codes for the monthly capitation payment are important opportunities to understand facility and provider behavior with particular attention to patient selection and treatment practices. Well-designed payment systems will reward quality care for patients while maintaining appropriate accountability and fairness for health care providers.

Background: In 2002, the Accreditation Council on Graduate Medical Education enacted regulations, effective 1 July 2003, that limited work hours for all residency programs in the United States.

Objective: To determine whether work-hour regulations were associated with changes in mortality in hospitalized patients.

Design: Comparison of mortality rates in high-risk teaching service patients hospitalized before and after July 2003, with nonteaching service patients used as a control group.

Setting: 551 U.S. community hospitals included in the Healthcare Cost and Utilization Project's Nationwide Inpatient Survey between January 2001 and December 2004.

Patients: 1,511,945 adult patients admitted for 20 medical and 15 surgical diagnoses.

Measurement: Inpatient mortality.

Results: In 1,268,738 medical patients examined, the regulations were associated with a 0.25% reduction in the absolute mortality rate (P = 0.043) and a 3.75% reduction in the relative risk for death. In subgroup analyses, particularly large improvements in mortality were observed among patients admitted for infectious diseases (change, -0.66%; P = 0.007) and in medical patients older than 80 years of age (change, -0.71%; P = 0.005). By contrast, in 243 207 surgical patients, regulations were not associated with statistically significant changes (change, 0.13%; P = 0.54).

Limitations: Teaching status was assigned according to hospital characteristics because direct information on each patient's provider was not available. Results reflect changes associated with the sum of regulations, not specifically with caps on work hours.

Conclusions: The work-hour regulations were associated with decreased short-term mortality among high-risk medical patients in teaching hospitals but were not associated with statistically significant changes among surgical patients in teaching hospitals.

This issue of CHP/PCOR's Quarterly Update covers news from the Spring 2007 quarter and includes articles about:

• the HIV/AIDS International Conference in St. Petersburg, Russia, that was attended by the CHP/PCOR National Institute on Drug Abuse project team;
• a special international health section that highlights HIV/AIDS research in Zimbabwe, and two Payne lecturer talks, given by David Heymann and Peter Piot, speaking on infectious diseases and HIV/AIDS, respectively;
• two Research in Brief selections -- one highlights health care financing structures in high-income countries, and the second covers an ongoing trial that incorporates a smoking cessation program into posttraumatic stress disorder treatment at the VA;
• a Staff Spotlight feature on new CHP/PCOR core faculty member Sally Horwitz;
• two conferences -- one hosted by the Stanford International Initiative and the other a National Summit on America's Children at the Capitol.