Dialysis Facility Ownership and Epoetin Dosing in Patients Receiving Hemodialysis

Thamer, Mae; Zhang, Yi; Kaufman, James S.; Cotter, Dennis J.; Dong, Fan; Hernán, Miguel A.

doi:10.1001/jama.297.15.1667

Cited by 107 publications

(70 citation statements)

References 32 publications

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“…22 A recent manuscript by Thamer et al presents similar findings from November to December 2004, demonstrating lower EPO use and fewer hematocrit levels Ն39% in DCI when compared with for-profit dialysis providers. 23 These findings suggest that anemia management practice patterns at DCI-affiliated units may differ from practice patterns at units affiliated with other national providers and provide a plausible explanation for the different results.…”

Section: Discussionmentioning

confidence: 80%

Reducing versus Discontinuing Erythropoietin at High Hemoglobin Levels

Weiner¹,

Miskulin²,

Seefeld³

et al. 2007

Journal of the American Society of Nephrology

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A 2006 change in Medicare policy allowed reimbursement for erythropoietin (EPO) in dialysis patients whose most recent hemoglobin exceeded 13 g/dl. We investigated the effects of a change in dosing algorithm implemented in response to this policy, in which EPO dosages were reduced instead of temporarily discontinued for hemoglobin levels Ն13 g/dl. Among 1688 individuals in 18 hemodialysis units, the reduction protocol resulted in more hemoglobin levels Ն13 g/dl (P Ͻ 0.0001), fewer levels between 11 and 12.9 g/dl (P Յ 0.004), no difference in the proportion of levels Ͻ11 g/dl, and more EPO administered per session (P Ͻ 0.0001) than the discontinuation protocol. In view of the expense of erythropoiesis stimulating agents and the uncertainty of the safety of using EPO to achieve high hemoglobin targets, this study suggests that discontinuation, rather than reduction, of EPO treatment is appropriate when hemoglobin reaches 13 g/dl in hemodialysis patients.

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Section: Discussionmentioning

confidence: 80%

Reducing versus Discontinuing Erythropoietin at High Hemoglobin Levels

Weiner¹,

Miskulin²,

Seefeld³

et al. 2007

Journal of the American Society of Nephrology

View full text Add to dashboard Cite

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“…11,12 The evidence from randomized trials is especially significant in light of a recent report showing that for-profit dialysis chains administer higher epoetin doses even when hemoglobin is within the 11 to 12 g/dl range, and have a higher proportion of patients with hemoglobin Ͼ12 g/dl. 13,14 Preliminary evidence suggests the effects of hemoglobin on clinical outcomes may not be captured by the absolute level of hemoglobin alone. Measures of their change over time have also been associated with adverse patient outcomes.…”

mentioning

confidence: 99%

Hemoglobin Variability and Mortality in ESRD

Yang

Israni

Brunelli

et al. 2007

Journal of the American Society of Nephrology

182

165

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Hemoglobin levels vary substantially over time in hemodialysis patients, and this variability may portend poor outcomes. For a given patient, hemoglobin concentration over time can be described by absolute levels, rate of change, or by the difference between observed level and expected level based on the preceding trend (i.e., seemingly random variability). We investigated the independent associations of these different methods of describing hemoglobin over time with mortality in a retrospective cohort of 34,963 hemodialysis patients. Hemoglobin concentration over time was modeled with linear regression for each subject, and the model was then used to define the subject's absolute level of hemoglobin (intercept), temporal trend in hemoglobin (slope), and hemoglobin variability (residual standard deviation). Survival analyses indicated that each 1g/dl increase in the residual standard deviation was associated with a 33% increase in rate of death, even after adjusting for multiple covariates. Patient characteristics accounted for very little of the variation in our hemoglobin variability metric (R 2 ϭ 0.019). We conclude that greater hemoglobin variability is independently associated with higher mortality.

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“…14 -17 Recent analyses of USRDS data also suggest that considerably higher amounts of ESA are prescribed in for-profit dialysis care providers, leading to higher hemoglobin levels than other dialysis centers. 14,18,19 This may be related to the high profit margin from the ESA trades and utilization or simply a natural trend in patient care. 20 …”

mentioning

confidence: 99%