Ebben James P, Gilbertson David T, Foley Robert N, Collins Allan J
Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN 55404, USA.
Clin J Am Soc Nephrol. 2006 Nov;1(6):1205-10. doi: 10.2215/CJN.01110306. Epub 2006 Sep 6.
National payment policies target a hemoglobin range of 11 to 12.5 g/dl for patients with ESRD. However, clinical complications and provider practices may contribute to wide fluctuations over time. This study evaluated the frequency with which patients maintain stable hemoglobin levels below, within, and above the Centers for Medicare & Medicaid Services target range and assessed patterns of hemoglobin level change that resulted in large fluctuations across the target range during a 6-mo period. All hemodialysis patients who survived the first 6 mo of 2003, had Medicare as primary payer, and had Medicare outpatient erythropoietin claims in each of the first 6 mo of 2003 (n = 152,846) were studied. Six patient groups were defined on the basis of patterns of hemoglobin level fluctuation: Consistently low (<11 g/dl), consistently target range (11 to 12.5 g/dl), consistently high (> or =12.5 g/dl), low-amplitude fluctuation with low hemoglobin levels, low-amplitude fluctuation with high hemoglobin levels, and high-amplitude fluctuation. Only 10.3% of patients maintained stable hemoglobin levels during the 6 mo and only 6.5% in the target range. The consistently low group had the highest percentage of hospitalizations and the highest number of comorbid conditions. High-amplitude fluctuation was the most common pattern (39.5%), with hemoglobin levels falling below and rising above the target range during the 6-mo period. Hemoglobin levels in almost 90% of patients are in some degree of flux at any point in time, and the fluctuation is highly associated with clinical complications and provider practices.
国家支付政策将终末期肾病患者的血红蛋白目标范围设定为11至12.5 g/dl。然而，临床并发症和医疗服务提供者的做法可能导致血红蛋白水平随时间大幅波动。本研究评估了患者在医疗保险与医疗补助服务中心（CMS）目标范围以下、范围内和以上维持稳定血红蛋白水平的频率，并评估了在6个月期间导致血红蛋白水平在目标范围内大幅波动的变化模式。对所有在2003年存活前6个月、以医疗保险作为主要支付方且在2003年前6个月每个月均有医疗保险门诊促红细胞生成素报销记录的血液透析患者（n = 152,846）进行了研究。根据血红蛋白水平波动模式定义了六个患者组：持续低水平（<11 g/dl）、持续处于目标范围（11至12.5 g/dl）、持续高水平（≥12.5 g/dl）、低血红蛋白水平的低幅度波动、高血红蛋白水平的低幅度波动以及高幅度波动。在6个月期间，只有10.3%的患者维持了稳定的血红蛋白水平，在目标范围内的仅占6.5%。持续低水平组的住院率最高，合并症数量也最多。高幅度波动是最常见的模式（39.5%），在6个月期间血红蛋白水平降至目标范围以下并升至目标范围以上。几乎90%的患者在任何时间点的血红蛋白水平都有一定程度的波动，且这种波动与临床并发症和医疗服务提供者的做法高度相关。
