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Some Dialysis Centers Overtreat Anemia: Study

The practice may put kidney patients at risk of complications, researchers say

TUESDAY, April 17, 2007 (HealthDay News) -- People receiving dialysis at large for-profit dialysis centers may be getting over-treated for anemia, a common complication in people with kidney disease, and that might be putting their health at risk, a new study contends.

The typical hospital-based dialysis center administered an average dose of 16,188 units per week of epoetin, a drug that helps correct anemia. Conversely, for-profit chain facilities administered and average of 20,838 units a week. For-profit facilities used an average of about 3,300 units per week more than nonprofit dialysis centers, according to the study.

"Basically what we found in the area of anemia management is there are wide differences in practice," said study author Mae Thamer, a senior associate at the Medical Technology and Practice Patterns Institute in Bethesda, Md. "We found that large for-profit dialysis centers were much more likely to prescribe the highest doses of epoetin."

The problem, Thamer explained, is that this practice may lead to serious complications, including an increased risk of death for patients who receive too much epoetin.

The findings are published in the April 18 issue of the Journal of the American Medical Association.

So, why would centers overuse the medication? Possibly because it's one of the few treatments for end-stage kidney disease that's readily reimbursed by Medicare. In fact, epoetin comprised 11 percent of all Medicare costs for end-stage kidney disease, with almost $2 billion in payouts for the drug in 2004, according to the study. Up to 25 percent of a dialysis center's profits may come from epoetin, according to an accompanying editorial in the journal.

Epoetin is a synthetic version of a hormone normally produced by the kidneys called erythropoietin. This hormone stimulates the bone marrow to produce red blood cells, which carry oxygen to all of the other cells in the body. People with kidney disease don't always produce enough erythropoietin, and anemia -- a shortage of red blood cells -- can result.

There's still some debate about what the optimal levels of treatment should be. Current recommendations from the U.S. Food and Drug Administration suggest that hemoglobin levels (a measure of oxygen-carrying capacity of red blood cells) should be maintained under 12 grams per deciliter (g/dl), but the most recent guidelines from the National Kidney Foundation allow for up to 13 g/dl. Once hemoglobin levels in kidney patients exceed 12 g/dl, the risk of heart attack, stroke, heart failure and blood clots increase, according to the editorial.

"The trials to date indicate that maintaining hemoglobin levels above 12 is not in (kidney patients') long-term interest," said Dr. Daniel Coyne, author of the editorial and a professor of medicine at Washington University School of Medicine, in St. Louis.

Coyne said the National Kidney Foundation will be re-examining its guidelines, beginning this month.

In the new study, Thamer and her colleagues compared the treatment received at nonprofit and for-profit dialysis centers for nearly 160,000 dialysis patients during November and December 2004. Eighty-two percent of those included in the study were treated at for-profit centers.

The researchers found vast differences in the way anemia was treated, depending on the type of center where someone received dialysis, with for-profit facilities administering roughly a third more units of epoetin per week.

Thamer and her colleague, Dennis Cotter, president of Medical Technology and Practice Patterns Institute, believe a better way to reimburse centers for epoetin would be to include it in the standard payment given to centers for dialysis, called the "composite reimbursement." Doing so would take away any potential financial incentive for over-treating a patient, they suggested.

And, while each individual patient needs a varying dose of epoetin to combat anemia, Cotter said, "Reimbursement for (each patient) would be based from a population standpoint," which would average the reimbursement to account for individual variations.

Coyne agreed that tying epoetin payments into the composite reimbursement was a good idea. "Reimbursement needs to be tied to providing dialysis. Right now, we offer perverse incentives where wasting epoetin is beneficial," he said.

More information

To learn more about how anemia develops in people on dialysis, visit the National Institute of Diabetes and Digestive and Kidney Diseases.

SOURCES: Dennis Cotter, M.S.E., president, and Mae Thamer, Ph.D., senior associate, Medical Technology and Practice Patterns Institute, Bethesda, Md.; Daniel Coyne, M.D., professor, medicine, Washington University School of Medicine, St. Louis; April 18, 2007, Journal of the American Medical Association
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