title: Blood transfusion practices in dialysis patients in a dynamic regulatory environment.
abstract: BACKGROUND
  In 2011, Medicare implemented a prospective payment system (PPS) covering an expanded bundle of services that excluded blood transfusions. This led to concern about inappropriate substitution of transfusions for other anemia management methods.
  
  
  METHODS
  Medicare claims were used to calculate transfusion rates among dialysis patients pre- and post-PPS. Linear probability regressions adjusted transfusion trends for patient characteristics.
  
  
  METHODS
  Dialysis patients for whom Medicare was the primary payer between 2008 and 2012.
  
  
  METHODS
  Pre-PPS (2008-2010) versus post-PPS (2011-2012).
  
  
  METHODS
  Monthly and annual probability of receiving one or more blood transfusions.
  
  
  RESULTS
  Monthly rates of one or more transfusions varied from 3.8%-4.8% and tended to be lowest in 2010. Annual rates of transfusion events per patient were -10% higher in relative terms post-PPS, but the absolute magnitude of the increase was modest (-0.05 events/patient). A larger proportion received 4 or more transfusions (3.3% in 2011 and 2012 vs 2.7%-2.8% in prior years). Controlling for patient characteristics, the monthly probability of receiving a transfusion was significantly higher post-PPS (β = 0.0034; P < 0.001), representing an -7% relative increase. Transfusions were more likely for females and patients with more comorbid conditions and less likely for blacks both pre- and post-PPS.
  
  
  CONCLUSIONS
  Possible underidentification of transfusions in the Medicare claims, particularly in the inpatient setting. Also, we do not observe which patients might be appropriate candidates for kidney transplantation.
  
  
  CONCLUSIONS
  Transfusion rates increased post-PPS, but these increases were modest in both absolute and relative terms. The largest increase occurred for patients already receiving several transfusions. Although these findings may reduce concerns regarding the impact of Medicare's PPS on inappropriate transfusions that impair access to kidney transplantation or stress blood bank resources, transfusions should continue to be monitored.
authors.affiliation: School of Public Health, Health Management & Policy, University of Michigan, Ann Arbor, MI. Electronic address: rhirth@umich.edu.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Hirth
authors.affiliation: Arbor Research Collaborative for Health, University of Michigan, Ann Arbor, MI.
authors.forename: Marc N
authors.initials: MN
authors.lastname: Turenne
authors.affiliation: School of Public Health, Health Management & Policy, University of Michigan, Ann Arbor, MI.
authors.forename: Adam S
authors.initials: AS
authors.lastname: Wilk
authors.affiliation: School of Public Health, Health Management & Policy, University of Michigan, Ann Arbor, MI.
authors.forename: John R C
authors.initials: JR
authors.lastname: Wheeler
authors.affiliation: School of Public Health, Biostatistics, University of Michigan, Ann Arbor, MI.
authors.forename: Kathryn K
authors.initials: KK
authors.lastname: Sleeman
authors.affiliation: School of Public Health, Health Management & Policy, University of Michigan, Ann Arbor, MI.
authors.forename: Wei
authors.initials: W
authors.lastname: Zhang
authors.affiliation: Research & Data Analysis Division, Washington State Department of Social and Health Services, Olympia, WA.
authors.forename: Matthew A
authors.initials: MA
authors.lastname: Paul
authors.affiliation: School of Public Health, Health Management & Policy, University of Michigan, Ann Arbor, MI.
authors.forename: Tammie A
authors.initials: TA
authors.lastname: Nahra
authors.affiliation: Internal Medicine, Division of Nephrology, University of Michigan Health System, Ann Arbor, MI.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Messana
mesh_terms: D000740:Anemia / Q000209:etiology / Q000628:therapy*; D001803:Blood Transfusion / Q000191:economics*; D015897:Comorbidity; D004608:Eligibility Determination; D005260:Female; D006801:Humans; D007345:Insurance Claim Review; D007676:Kidney Failure, Chronic / Q000150:complications / Q000191:economics / Q000453:epidemiology / Q000628:therapy; D008297:Male; D006278:Medicare / Q000191:economics; D008875:Middle Aged; D010346:Patient Care Management / Q000191:economics; D011336:Probability; D011445:Prospective Payment System / Q000706:statistics & numerical data*; D006435:Renal Dialysis / Q000191:economics / Q000706:statistics & numerical data; D014481:United States
keywords: Medicare; Transfusion; anemia; composite rate services; costs; dialysis; end-stage renal disease (ESRD); incentives; kidney transplantation eligibility; medications; prospective payment