Variability in Cinacalcet Prescription across US Hemodialysis Facilities

Abstract

Background and objectives Calcimimetic drugs used to treat secondary hyperparathyroidism are being considered for inclusion in the Medicare ESRD Prospective Payment System bundle after an evaluation period. Understanding of utilization patterns of calcimimetics across dialysis facilities may help align financial incentives with clinical objectives. Our study's purpose was to describe the distribution of cinacalcet prescription across United States hemodialysis facilities and to explore factors that may influence cinacalcet utilization.Design, setting, participants, & measurements We used monthly cross-sectional data from the Dialysis Outcomes and Practice Patterns Study in 2014 to characterize the distribution of cinacalcet prescription across 203 United States hemodialysis facilities (10,521 patients). On the basis of associations with parathyroid hormone levels from patient-level analyses, we used linear mixed-effects regressions to estimate the associations between three facilitylevel exposures (black race, ,65 years old, and having $3 years on dialysis [vintage]) and the prevalence of cinacalcet prescription, adjusting for facility-and patient-level potential confounders. ResultsThe mean percentage of patients in each facility with cinacalcet prescription was 23% in June 2014 (median, 22%; interquartile range, 13%-30%). Adjusted for facility-level and nonexposure patient-level variables, the difference in prevalence of cinacalcet prescription between facilities with the highest and lowest quartiles of percentage of black patients was 7.8% (95% confidence interval [95% CI], 0.8% to 14.8%; P for trend =0.03). The adjusted prevalence difference was 7.3% for the percentage of patients aged ,65 years (95% CI, -0.1% to 14.7%; P for trend =0.06) and 11.9% for the percentage of patients with $3 years of dialysis (95% CI, 2.4% to 21.4%; P for trend =0.02). These associations changed appreciably, becoming much weaker or even reversing, after further adjusting for the patient-level exposure variables.Conclusions Facilities treating more patients who are black, under age 65 years, and having dialysis vintage $3 years have higher average levels of cinacalcet prescription. However, these differences were strongly attenuated after accounting for the unbalanced distributions of these patient case-mix variables.

International and Racial Differences in Mineral and Bone Disorder Markers and Treatments Over the First 5 Years of Hemodialysis in the Dialysis Outcomes and Practice Patterns Study

“…21 Another possibility is that genetic differences could influence the ability to control PTH levels in different racial groups. Recent work by Fuller et al 22 has shown higher PTH levels despite greater cinacalcet use among black/ African American versus non-black/African American US HD patients. Further studies are needed to determine whether inherited or other factors explain higher PTH levels among US black/African American patients and how such factors may affect therapeutic approaches to improve PTH management and ultimately minimize consequent bone and cardiovascular complications.…”

Calcimimetic Use in Dialysis-Dependent Medicare Fee-for-Service Beneficiaries and Implications for Bundled Payment

“…At the aggregate level, the patient characteristics and given previous research that has identified an association between vintage and cinacalcet utilization. 10 Although prior studies have identified an association between these baseline characteristics and calcimimetic use, this analysis is (to our knowledge) the first time the 100% sample of the Medicare Part B claims has been utilized (1) to describe variation in both cinacalcet and etelcalcetide utilization and (2) to assess utilization patterns of calcimimetics in the Medicare population during the TDAPA period for both these therapies.…”

“…8 More frequent monitoring may be required for patients with SHPT who are treated with calcimimetics to reach their target maintenance dose. 9 10,11 The dialysis facility identifier listed on each beneficiary's first observed maintenance dialysis claim in 2018 was captured from the Part B claims and cross-referenced to the current CMS Dialysis Facility Compare public use files. 12 For each dialysis provider, the following…”

New Intravenous Calcimimetic Agents: New Options, New Problems. An Example on How Clinical, Economical and Ethical Considerations Affect Choice of Treatment

“…While this pragmatic approach may be seen as ethically disturbing since it heavily impacts on a clinical choice, it also underlines the potential strength of scientific societies in the discussion on treatment costs and availability, which in turn influence clinical choices [32][33][34][35][36][37].…”

“…The way dialysis is reimbursed plays an important role, since the intravenous drugs administered during the dialysis session are usually part of the dialysis budget (dialysis "bundle") and previous experience with erythropoietin clearly shows that the method of reimbursement deeply affects clinical practice [34][35][36][37][38][39]. Conversely, oral drugs are usually outside the dialysis budget, and this is frequently the case for first generation oral calcimimetic agents.…”