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Adherence Guidelines for ESRD Anemia Management: Implications for Cost and Quality of Care

Hynes DM, Stroupe KS, Browning MM, Kaufman JS, Reda DJ, Peterman A, Huo Z. Adherence Guidelines for ESRD Anemia Management: Implications for Cost and Quality of Care. Paper presented at: VA HSR&D National Meeting; 2005 Feb 1; Baltimore, MD.

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Objectives:A costly component of end-stage renal disease care for hemodialysis patients is anemia management with recombinant human erythropoietin (epoetin). National Kidney Foundation (NKF) clinical practice guidelines recommend that epoetin be administered subcutaneously rather than intravenously, given that target hemoglobin can be maintained with a lower subcutaneous dose. Since reimbursement for epoetin differs for federal versus private-sector dialysis centers, we hypothesized different use patterns by facility type. We also anticipated variation in cost attributable to these use patterns.Methods:Using data from a VA HSRandD-funded eight-site prospective observational study of hemodialysis patients from 2001-2003, we examined (1) compliance with guidelines across VA versus private-sector facilities and (2) implications for epoetin dose, anemia management, and cost.Results:Among 297 patients studied, epoetin was administered predominantly subcutaneously for 52% (91/174) of patients in VA facilities versus 15% (18/123) in private-sector facilities (p < 0.001). Average adjusted weekly subcutaneous epoetin dose was 13,656 and 12,962 units respectively at VA and private-sector facilities versus 18,907 and 20,019 units for intravenous epoetin (p < 0.02), with corresponding hemoglobin values 11.65 mg/dl and 12.22 mg/dl for subcutaneous and 11.34 mg/dl and 11.86 mg/dl for intravenous epoetin (p < 0.01). Yearly epoetin cost per patient for subcutaneous administration was $7,101 and $6,740 respectively at VA and private sector facilities, versus $9,831 and $10,410 for intravenous administration (p < 0.02).Implications:We found greater guideline adherence at VA facilities compared to the private sector, with lower epoetin costs maintaining target hemoglobin, although overall adherence is low. Patient preferences and financial incentives should be examined for their impact on wider utilization of subcutaneous epoetin administration.Impacts:Increasing adherence to NKF guidelines that recommend the subcutaneous route of administration for epoetin is a way to lower the very significant costs of providing care for patients with end-stage renal disease without compromising their essential anemia management. Future research should also investigate whether there are other clinical outcomes associated with the use of the subcutaneous route of administration for epoetin that might augment or offset these cost savings.

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