Thamer Mae, Zhang Yi, Kaufman James, Cotter Dennis, Dong Fan, Hernán Miguel A
Medical Technology and Practice Patterns Institute, Bethesda, Md 20814, USA.
JAMA. 2007 Apr 18;297(15):1667-74. doi: 10.1001/jama.297.15.1667.
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.
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.
Weekly mean epoetin dose administered in December 2004 and the adjustment in dose between November and December 2004.
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%.
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.
促红细胞生成素疗法用于治疗透析相关性贫血是医疗保险中单项最大的药物支出。患者接受透析的机构类型（营利性、连锁性及附属状况）可能会影响促红细胞生成素的给药模式，并对未来的促红细胞生成素政策产生影响。
研究透析机构所有权与促红细胞生成素给药剂量之间的关联。
设计、设置和参与者：利用美国肾脏数据系统的数据，确定了2004年11月和12月期间159522名符合医疗保险条件的成年终末期肾病患者，他们正在接受中心血液透析。采用回归模型来估计促红细胞生成素的平均剂量以及根据营利性、连锁性和附属状况进行的剂量调整。
2004年12月每周促红细胞生成素的平均给药剂量以及2004年11月至12月期间的剂量调整情况。
与非营利性透析机构的患者（n = 28199）相比，大型营利性透析连锁机构的患者（n = 106116）无论贫血状况如何，始终接受最高剂量的促红细胞生成素。与非营利性机构相比，营利性机构平均每周多使用3306单位的促红细胞生成素。在6家患者病例组合相似的大型连锁机构中，促红细胞生成素的平均剂量范围为，连锁机构5为每周17832单位（非营利性机构，平均血细胞比容水平为34.6%），连锁机构2为每周24986单位（营利性机构，平均血细胞比容水平为36.5%）。剂量调整也因机构类型而异。平均而言，与非营利性机构相比，营利性机构对血细胞比容水平低于33%的患者将促红细胞生成素剂量增加了3倍，对血细胞比容水平在推荐目标范围33%至36%的患者也增加了剂量，尤其是在最大的营利性连锁机构中。在血细胞比容水平低于33%的患者中，各机构之间给药实践模式的差异最大。
在美国，透析机构的组织状况和所有权与促红细胞生成素给药的差异有关。不同的促红细胞生成素给药模式表明，大型营利性连锁机构使用了更大的剂量调整，并将更高的血细胞比容水平作为目标。
