Original Investigation
Dialysis Therapy
Adherence to Guidelines for ESRD Anemia Management

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Background: A costly component of end-stage renal disease care is anemia management with recombinant human erythropoietin. National Kidney Foundation clinical practice guidelines recommend that erythropoietin be administered subcutaneously, rather than intravenously, given that the target hemoglobin level can be maintained with a lower subcutaneous dose. Because reimbursement for erythropoietin differs for federal versus private-sector dialysis centers, we hypothesized different use patterns by facility type. Methods: Using data from a multisite prospective observational study of hemodialysis patients from 2001 to 2003, we examined compliance with erythropoietin administration guidelines across Veterans Affairs (VA) versus private-sector facilities and implications for erythropoietin dose, anemia management, and cost. Results: Erythropoietin was administered predominantly subcutaneously for 52% of patients in VA versus 15% in private-sector facilities (P < 0.0001). Average adjusted weekly subcutaneous erythropoietin doses were 13,710 and 13,362 units at VA and private-sector facilities versus 19,453 and 21,237 units for intravenous erythropoietin (P = 0.01), with corresponding hemoglobin levels of 11.55 and 12.34 g/dL (115.5 and 123.4 g/L) for subcutaneous and 11.38 and 11.91 g/dL (113.8 and 119.1 g/L) for intravenous erythropoietin (P = 0.0002), respectively. Yearly erythropoietin costs per patient for subcutaneous administration were $7,129 and $6,948 at VA and private-sector facilities versus $10,116 and $11,043 for intravenous administration (P = 0.01), respectively. Conclusion: We found greater guideline adherence at VA facilities compared with the private sector, with lower erythropoietin costs, although overall adherence is low. Anemia management was similar. Future research should examine how patient preferences and financial incentives impact on the wider use of subcutaneous erythropoietin administration.

Section snippets

Study Design

Data for this study were from a prospective observational study comparing outcomes and costs of care of veterans dialyzing at VA facilities or in the private sector. Patients were enrolled from August 2001 through December 2003. Any patient who had received care at a VA facility within the prior 3 years and was receiving hemodialysis for end-stage renal disease was eligible for enrollment. Patients were excluded if they: (1) had a live kidney donor identified; (2) required skilled nursing

Demographic and Clinical Characteristics of Patient Sample

Demographic and clinical characteristics of patients by facility type are listed in Table 1. Compared with patients dialyzing at private-sector facilities, patients dialyzing at VA facilities were on average younger, more likely to be African American, and less likely to be enrolled in Medicare. Hemoglobin level at baseline for patients dialyzing at VA facilities was lower on average (11.41 versus 12.25 g/dL [114.1 versus 122.5 g/L]). The 36 excluded patients were similar to included subjects

Discussion

We found greater adherence to the clinical practice guideline for subcutaneous route of epoetin administration in VA than private-sector facilities. For 52% of patients receiving regular hemodialysis in VA facilities, subcutaneous was the predominant route of epoetin administration, whereas only 15% of patients in private-sector facilities were administered epoetin predominantly subcutaneously. However, overall adherence to the NKF-KDOQI guideline was low.

Although there is no definitive

Acknowledgment

R. Cxypoliski; N. Pastore; P. Ivanovich, MD; C. Manno; G. Dolson, MD; G. Tasby; R. Agarwal, MD; N. Sachs; G. Shah, MD; C. Molina; A. Mogyorosi, MD; G. Feldman, MD; S. Schmid; D. Sherrard, MD; E. Ayers; C. Stehman-Breen, MD; V. Gandhi, MD; S. Popli, MD; and C. Schneiderman were members of the ESRD Cost Study Group.

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Support: This research was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (Project no. ECI 20-016). Dr Kaufman receives grants and honoraria from Amgen and Roche. Potential conflicts of interest: None.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

Originally published online as doi:10.1053/j.ajkd.2005.11.012 on February 2, 2006.

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