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Dialysis Facility Ownership and Epoetin Dosing in Patients Receiving Hemodialysis
Mae Thamer, PhD;
Yi Zhang, MS;
James Kaufman, MD;
Dennis Cotter, MSE;
Fan Dong, BS;
Miguel A. Hernán, MD
JAMA. 2007;297:1667-1674.
Context Epoetin therapy for dialysis-related anemia is the single largest Medicare drug expenditure. The type of facility (profit, chain, and affiliation status) at which a patient receives dialysis might affect epoetin dosing patterns and has implications for future epoetin policies.
Objective To examine the association between dialysis facility ownership and the dose of epoetin administered.
Design, Setting, and Participants Data from the US Renal Data System were used to identify 159 522 adult Medicare-eligible, end-stage renal disease patients receiving in-center hemodialysis during November and December 2004. Regression models were used to estimate the mean epoetin dose and dose adjustment by profit, chain, and affiliation status.
Main Outcome Measures Weekly mean epoetin dose administered in December 2004 and the adjustment in dose between November and December 2004.
Results Compared with patients in nonprofit dialysis facilities (n = 28 199), patients in large for-profit dialysis chain facilities (n = 106 116) were consistently administered the highest doses of epoetin regardless of anemia status. Compared with nonprofit facilities, for-profit facilities administered, on average, an additional 3306 U/wk of epoetin. Among the 6 large chain facilities with a similar patient case-mix, the average dose of epoetin ranged from 17 832 U/wk at chain 5 (nonprofit facilities with a mean hematocrit level of 34.6%) to 24 986 U/wk at chain 2 (for-profit facilities with a mean hematocrit level of 36.5%). Dosing adjustments also differed by type of facility. On average, compared with nonprofit facilities, for-profit facilities increased epoetin doses 3-fold for patients with hematocrit levels of less 33% and also increased the doses among patients with hematocrit levels in the recommended target of 33% to 36%, especially in the largest for-profit chain facilities. The greatest difference in dosing practice patterns between facilities was found among patients with hematocrit levels of less than 33%.
Conclusions Dialysis facility organizational status and ownership are associated with variation in epoetin dosing in the United States. Different epoetin dosing patterns suggest that large for-profit chain facilities used larger dose adjustments and targeted higher hematocrit levels.
Author Affiliations: Medical Technology and Practice Patterns Institute, Bethesda, Md (Dr Thamer, Ms Zhang, and Messrs Cotter and Dong); Renal Section, Veterans Affairs Boston Healthcare Systems and Boston University School of Medicine, Boston, Mass (Dr Kaufman); and Department of Epidemiology, Harvard School of Public Health, Boston, Mass (Dr Hernán).
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