EPO Adjustments in Patients With Elevated Hemoglobin Levels: Provider Practice Patterns Compared With Recommended Practice Guidelines

Background

This study investigates provider practices regarding recombinant human erythropoietin (rHuEPO) dose when patient hemoglobin levels exceeded National Kidney Foundation–Dialysis Outcomes Quality Initiative target levels and reached 13 g/dL or greater (≥130 g/L).

Methods

The study population (N = 167,796) was hemodialysis patients prevalent on January 1, 2003, who were on renal replacement therapy at least 90 days with Medicare as primary payer and rHuEPO claims in 2 or more consecutive months. Patient characteristics were obtained from the Centers for Medicare & Medicaid Services (CMS) Medical Evidence Report, and comorbid conditions were determined from Medicare claims. Providers and rHuEPO claims were linked by using CMS-assigned provider numbers and the CMS Annual End-Stage Renal Disease Facility Survey. Between-provider differences in patient characteristics were examined by using chi-square test, and provider effect on appropriate response, by using logistic regression.

Results

DaVita’s percentage of monthly claims for patients with hemoglobin levels of 13 g/dL or greater (≥130 g/L; 16.7%) and mean monthly rHuEPO dose (54,299 units) were highest. Dialysis Clinic Inc’s percentage of such claims (2.0%) and mean monthly dose (38,687 units) were lowest. Dialysis Clinic Inc, Fresenius, and Renal Care Group had the highest percentage of recommended dose adjustments (mean, 70% of units); hospital-based units had the lowest (59%). By adjusted odds ratio, adjustments were 20% more likely for Dialysis Clinic Inc, Fresenius, and Renal Care Group compared with DaVita, National Nephrology Associates, hospital-based units, and independents (17% to 28% less likely).

Conclusion

rHuEPO dose reduction practices are dependent on specific dialysis providers and whether units are hospital based or independent.

Index words: Hematocrit, hemodialysis (HD), hemoglobin, recombinant human erythropoietin