Factors influencing the route of administration for Epoetin treatment among hemodialysis patients in the U.S.

A forthcoming article to be published in the July 2006 issue of the American Journal of Kidney Diseases finds that physician decision-making for the delivery of epoetin therapy is primarily influenced by the type of ownership and financial incentives associated with dialysis centers.

The study, Factors Influencing the Route of Administration for Epoetin Treatment Among Hemodialysis Patients in the United States, was conducted by authors from MTPPI and from the Boston VA. Thamer et al. concluded that given the similar effectiveness but significantly reduced dose associated with subcutaneous (SC) epoetin, this study suggests an enormous opportunity for cost-savings for the Medicare program.

All current guidelines, including the U.S.-generated National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) and the European and Canadian national guidelines for anemia management, recommend SC administration for hemodialysis patients based on best evidence. However, in the U.S. only 7% of all hemodialysis patients receive epoetin via SC route with important implications in terms of the dose, frequency of administration, costs, and, potentially, outcomes. Despite this disparity between the recommended guidelines and real world practice, few studies have examined the factors associated with route of administration of epoetin therapy among hemodialysis patients.

Using data from a survey by the Centers of Medicaid&Medicare Services, Thamer et al. identified 13,854 patients receiving hemodialysis in 3,069 dialysis facilities from October-December 1999 and 2000. The authors found that in the U.S., use of SC route of epoetin administration varied widely across the country. After adjusting for patient sociodemographics and comorbidities, the highest rates of SC therapy are found in the Midwest and West, among providers not affiliated with chains, and in hospital-based and not-for-profit freestanding units. Previous exposure to SC administration (as a predialysis or peritoneal dialysis patient) predicted subsequent SC use; for-profit and large chains were significantly less likely to use SC administration; and increased use of injectable drugs overall (to maximize income) was associated with less SC use.

Notably, Thamer et al. found that hemodialysis patients at freestanding for-profit centers were significantly less likely to receive SC epoetin compared to hemodialysis patients at not-for profit and hospital-based centers suggesting that ownership of a health care facility influences clinical decision-making in the treatment of anemia. Furthermore, the larger the chain, the smaller the proportion of patients using SC route of epoetin administration. The authors speculate that the volume discounts for supplies or drugs such as epoetin that are typically provided to large chains may explain this finding. Given the smaller profits associated with SC epoetin, treatment guidelines alone are not likely to be effective in promoting SC route of administration. Since epoetin is expensive, however, optimizing its therapeutic effect by using subcutaneous administration could lead to substantial cost savings to the Medicare program; one study found that SC use could result in annual per patient savings of $1,761. Research was supported in part by NIH grant R01-DK066011-01A2.


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