title: Erythropoiesis-stimulating agent use after changes in medicare reimbursement policies.
abstract: OBJECTIVE
  Since 2004, concerns about the safety of erythropoiesis-stimulating agents (ESAs) have resulted in label changes and restrictions on their use. We examined changes in ESA use and blood transfusions over time.
  
  
  METHODS
  The SEER-Medicare database was used to identify patients age ≥ 65 years with breast, lung, prostate, ovary, or colon cancer, diagnosed between 2000 and 2007, who had a chemotherapy claim after their cancer diagnosis. We calculated the mean number of ESA claims per patient per year. Follow-up claims were available through 2008. We used multivariable logistic regression models to analyze the association of ESA use and extended ESA use with clinical and demographic variables.
  
  
  RESULTS
  Among 121,169 patients identified, 46,063 (38%) received an ESA. ESA use increased from 12.4% to 16.2% by 2006 and then decreased to 7.9% by 2008. Similarly, the mean number of ESA claims per patient decreased steadily over the entire timeframe. The annual percentage of patients undergoing transfusion remained relatively constant (9% to 10%). In a Cox proportional hazards time-dependent model, ESA use was positively associated with black race (odds ratio [OR], 1.11; 95% CI, 1.07 to 1.15), metropolitan location (OR, 1.17; 95% CI, 1.13 to 1.21), metastatic disease (OR, 1.39; 95% CI, 1.35 to 1.41), female sex (OR, 1.17; 95% CI, 1.14 to 1.20), > one comorbidity (OR, 1.29; 95% CI, 1.25 to 1.32), and tumor type. The number of denied claims increased over time.
  
  
  CONCLUSIONS
  Our study demonstrated a rapid decline in the percentage of patients treated with ESAs after changes to reimbursement policy, but not after warnings about use. Reimbursement restrictions of other overused or off-label drugs may help reduce health care expenditures.
authors.affiliation: Columbia University College of Physicians and Surgeons and Mailman School of Public Health; and New York Presbyterian Hospital, New York, NY dlh23@columbia.edu.
authors.forename: Dawn L
authors.initials: DL
authors.lastname: Hershman
authors.affiliation: Columbia University College of Physicians and Surgeons and Mailman School of Public Health; and New York Presbyterian Hospital, New York, NY.
authors.forename: Alfred I
authors.initials: AI
authors.lastname: Neugut
authors.affiliation: Columbia University College of Physicians and Surgeons and Mailman School of Public Health; and New York Presbyterian Hospital, New York, NY.
authors.forename: Jin Joo
authors.initials: JJ
authors.lastname: Shim
authors.affiliation: Columbia University College of Physicians and Surgeons and Mailman School of Public Health; and New York Presbyterian Hospital, New York, NY.
authors.forename: Sherry
authors.initials: S
authors.lastname: Glied
authors.affiliation: Columbia University College of Physicians and Surgeons and Mailman School of Public Health; and New York Presbyterian Hospital, New York, NY.
authors.forename: Wei-Yann
authors.initials: WY
authors.lastname: Tsai
authors.affiliation: Columbia University College of Physicians and Surgeons and Mailman School of Public Health; and New York Presbyterian Hospital, New York, NY.
authors.forename: Jason D
authors.initials: JD
authors.lastname: Wright
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000191:economics; D005260:Female; D006397:Hematinics / Q000008:administration & dosage* / Q000191:economics*; D006801:Humans; D007349:Insurance, Health, Reimbursement / Q000191:economics* / Q000706:statistics & numerical data; D008297:Male; D006278:Medicare / Q000191:economics* / Q000706:statistics & numerical data; D009369:Neoplasms / Q000097:blood / Q000188:drug therapy* / Q000191:economics*; D017063:Outcome Assessment, Health Care / Q000191:economics / Q000706:statistics & numerical data; D018426:SEER Program; D014481:United States
chemical_list: D000970:Antineoplastic Agents; D006397:Hematinics
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