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Mortality rates stable after bundled dialysis payments.


SAN DIEGO--Since the January 2011 move to bundled Medicare payments for outpatient dialysis services, mortality and hospitalizations appear to be stable among chronic kidney disease patients--but there have been dramatic trends toward lower hemoglobin levels and less use of intravenous epoetin, along with a rise in transfusions.

The findings come from the latest review of data contained in the Dialysis Outcomes and Practice Patterns Study (DOPPS) Practice Monitor, an ongoing effort to provide up-to-date trends in clinical care for dialysis patients.

During a special session at the meeting, Dr. Bruce M. Robinson, a nephrologist and vice president for clinical research at Arbor Research Collaborative for Health in Ann Arbor, Mich., presented findings from a stratified random sample of more than 5,000 hemodialysis patients who were treated at about 140 dialysis facilities in the United States between August 2010 and April 2012.

Over that time period, the dialysis landscape changed dramatically, Dr. Robinson said.

Not only did Medicare launch its Prospective Payment System (PPS), but the Food and Drug Administration also modified dosing recommendations for erythropoietin-stimulating agents (such as epoetin) in patients with chronic kidney disease. In addition, new anemia guidelines debuted from Kidney Disease: Improving Global Outcomes (KDI-GO), a global organization managed by the National Kidney Foundation. Finally, "a lot of folks are focused on what's going to happen with the expected introduction of oral renal medications in the bundle in January 2014," said Dr. Robinson.

Since the introduction of the PPS, there has been no clear trend in mortality or hospitalizations, based on DOPPS data corroborated by Medicare claims data. Mortality ranged between 1.5% and 2% per month, or "close to 20% per year," said Dr. Robinson. "There certainly remains substantial room for improvement."

Hospitalizations stand at around 15%, "which has been flat over the study period," he said. "This translates into about two hospitalizations per patient per year."

He went on to report four key trends related to anemia management in the DOPPS data:

* First, median hemoglobin levels declined by 0.62 g/dL over the study period. "We have about 16% of patients overall with a hemoglobin level of less than 10 g/dL, and about 4% with hemoglobin less than 9 g/dL," Dr. Robinson said.

* Second, median weekly IV epoetin doses declined by 31%. "The ceiling dose has dropped more substantially" he said. "The 90th percentile dose declined by 42%, while the 10th percentile dose declined by 21% and is now under 3,000 units per week."

* The third trend related to anemia management was observed in the rising proportion of patients who received IV iron, growing from 58% per month in August 2010 to 73% per month in April 2012.

"Clearly, there is movement toward more patients getting IV iron on a regular basis," Dr. Robinson said. "When we surveyed dialysis facility medical directors, about 75% of them told us that they're using maintenance IV iron dosing on a weekly or biweekly basis."

* The fourth trend related to anemia management was that median serum ferritin levels have increased by 28%. In fact, 39% of hemodialysis patients have ferritin levels at or above 800 ng/mL, and 10% of patients are at or above 1,200 ng/mL.

Dr. Robinson also reported that there has been an apparent rise in the percentage of patients receiving red blood cell transfusions, presenting Medicare claims data that indicated a 0.6% increase per month between November 2010 and November 2011.

"Making some assumptions, that translates to roughly 1 in 20 to 1 in 40 patients per year, so perhaps one additional patient per dialysis shift each year," he said.

In his opinion, this unwelcome trend may be preventable. In the DOPPS data, 12% of facilities reported at least 10% of their patients had hemoglobin levels less than 9 g/dL. DOPPS survey data indicate that 15% of facilities use a lower target for hemoglobin of 9 g/dL. It's this practice that likely raises transfusion risk.

In what Dr. Robinson characterized as a surprising finding, serum albumin levels rose during the study period, from a mean of 3.8 g/dL to a mean of 4.0 g/dL. "That's good news," he said. "The question is, why? It may be that this is due to greater use of oral nutritional supplements; but this topic needs further investigation."

The next update of the DOPPS Practice Monitor is scheduled for release this month.


Major Finding: The mortality of dialysis patients ranged from 1.5% to 2% per month, or close to 20% per year, while about 15% of dialysis patients were hospitalized.

Data Source: The data are from a stratified random sample of more than 5,000 hemodialysis patients in the United States who were treated at about 140 dialysis facilities between August 2010 and April 2012, corroborated by Medicare claims data.

Disclosures: Kidney Week 2012 was sponsored by the American Society of Nephrology. DOPPS is supported by scientific research grants from Abbott Laboratories, Amgen, Baxter Healthcare, Fresenius Medical Care, Kyowa Hakko Kirin, Sanofi Renal, and Vifor Fresenius Medical Care Renal Pharma without restrictions on publications. Dr. Robinson said that he had no other relevant financial conflicts to disclose.
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Title Annotation:NEPHROLOGY
Author:Brunk, Doug
Publication:Internal Medicine News
Date:Dec 1, 2012
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