title: Biomedical system dynamics to improve anemia control with darbepoetin alfa in long-term hemodialysis patients.
abstract: OBJECTIVE
  To determine the value of a biomedical system dynamics (BMSD) approach for optimization of anemia management in long-term hemodialysis patients because elevated hemoglobin levels and high doses of erythropoiesis-stimulating agents (ESAs) may negatively affect survival in this population.
  
  
  METHODS
  A model of erythropoiesis and its response to ESAs on the basis of a BMSD method (Mayo Clinic Anemia Management System [MCAMS]) was developed. Thereafter, an open-label, prospective, nonrandomized practice quality improvement project was performed with retrospective analysis in 8 community-based outpatient hemodialysis facilities. All prevalent hemodialysis patients seen from January 1, 2007, through December 31, 2010 (300-342 patients per month), were included with darbepoetin as the ESA. The primary outcome was the percentage of patients who attained the desired hemoglobin level. Secondary outcome measures included the percentage of patients with hemoglobin values above the desired range and mean dose of darbepoetin used.
  
  
  RESULTS
  The 3 treatment periods were (1) standard ESA protocol in 2007, (2) transition to the MCAMS (2008 to June 2009), and (3) stability period with the MCAMS used in all hemodialysis facilities (2009 to 2010). In the first 6 months of 2007, 69% of patients were in the desired range and 26% were above the range. In comparison, during the first 5 months of 2010, 83% were in and 6% were above the range (P<.001). The mean monthly darbepoetin dose per patient decreased from 304 μg in 2007 to 173 μg by the second half of 2009 (P<.001).
  
  
  CONCLUSIONS
  With the introduction of the MCAMS, more patients had hemoglobin levels in the desired range and fewer patients exceeded the target range, with a concomitant 40% reduction in darbepoetin use.
authors.affiliation: Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN. Electronic address: mccarthy.james@mayo.edu.
authors.forename: James T
authors.initials: JT
authors.lastname: McCarthy
authors.affiliation: Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
authors.forename: Craig L
authors.initials: CL
authors.lastname: Hocum
authors.affiliation: Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
authors.forename: Robert C
authors.initials: RC
authors.lastname: Albright
authors.affiliation: Advance Management Group, LLC, Rochester, MN.
authors.forename: James
authors.initials: J
authors.lastname: Rogers
authors.affiliation: Advance Management Group, LLC, Rochester, MN.
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Gallaher
authors.affiliation: Division of Hematologic Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA.
authors.forename: David P
authors.initials: DP
authors.lastname: Steensma
authors.affiliation: Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
authors.forename: Stephen F
authors.initials: SF
authors.lastname: Gudgell
authors.affiliation: Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Bergstralh
authors.affiliation: Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
authors.forename: John C
authors.initials: JC
authors.lastname: Dillon
authors.affiliation: Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
authors.forename: LaTonya J
authors.initials: LJ
authors.lastname: Hickson
authors.affiliation: Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
authors.forename: Amy W
authors.initials: AW
authors.lastname: Williams
authors.affiliation: Division of Hematology, Mayo Clinic, Rochester, MN.
authors.forename: David
authors.initials: D
authors.lastname: Dingli
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000740:Anemia / Q000188:drug therapy* / Q000209:etiology*; D000068256:Darbepoetin alfa; D004305:Dose-Response Relationship, Drug; D004920:Erythropoiesis / Q000187:drug effects*; D004921:Erythropoietin / Q000031:analogs & derivatives* / Q000627:therapeutic use; D005260:Female; D006397:Hematinics / Q000627:therapeutic use*; D006454:Hemoglobins / Q000032:analysis; D006801:Humans; D008297:Male; D008875:Middle Aged; D010346:Patient Care Management / Q000458:organization & administration*; D011446:Prospective Studies; D006435:Renal Dialysis / Q000009:adverse effects*; D012189:Retrospective Studies
chemical_list: D006397:Hematinics; D006454:Hemoglobins; D004921:Erythropoietin; D000068256:Darbepoetin alfa
keywords: BMSD; ESA; MCAMS; MCDS; Mayo Clinic Anemia Management System; Mayo Clinic Dialysis System; biomedical system dynamics; erythropoiesis-stimulating agent