title: Development of a standardized transfusion ratio as a metric for evaluating dialysis facility anemia management practices.
abstract: BACKGROUND
  Because transfusion avoidance has been the cornerstone of anemia treatment for patients with kidney disease, direct measurement of red blood cell transfusion use to assess dialysis facility anemia management performance is reasonable. We aimed to explore methods for estimating facility-level standardized transfusion ratios (STfRs) to assess provider anemia treatment practices.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Point prevalent US hemodialysis patients on January 1, 2009, with Medicare as primary payer and dialysis duration of 90 days or longer were included (n = 223,901). All dialysis facilities with eligible patients were included (n = 5,345).
  
  
  METHODS
  Dialysis facility assignment.
  
  
  RESULTS
  Receiving a red blood cell transfusion in the inpatient or outpatient setting.
  
  
  METHODS
  We evaluated 3 approaches for estimating STfR: ratio of observed to expected numbers of transfusions (STfR(obs)), a Bayesian approach (STfR(Bayes)), and a modified version of the Bayesian approach (STfR(modBayes)).
  
  
  RESULTS
  The overall national transfusion rate in 2009 was 23.2 per 100 patient-years. Our model for predicting the expected number of transfusions performed well. For large facilities, all 3 STfRs worked well. However, for small facilities, while the STfR(modBayes) worked well, STfR(obs) values demonstrated instability and the STfR(Bayes) may produce more bias.
  
  
  CONCLUSIONS
  Administration of transfusions to dialysis patients reflects medical practice both within and outside the dialysis unit. Some transfusions may be deemed unavoidable and transfusion practices are subject to considerable regional variation.
  
  
  CONCLUSIONS
  Development of an STfR metric is feasible and reasonable for assessing anemia treatment at dialysis facilities. The STfR(obs) is simple to calculate and works well for larger dialysis facilities. The STfR(modBayes) is more analytically complex, but facilitates comparisons across all dialysis facilities, including small facilities.
authors.affiliation: Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN.
authors.forename: Jiannong
authors.initials: J
authors.lastname: Liu
authors.affiliation: Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN.
authors.forename: Suying
authors.initials: S
authors.lastname: Li
authors.affiliation: Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN.
authors.forename: David T
authors.initials: DT
authors.lastname: Gilbertson
authors.affiliation: Center for Observational Research, Amgen, Inc, Thousand Oaks, CA.
authors.forename: Keri L
authors.initials: KL
authors.lastname: Monda
authors.affiliation: Center for Observational Research, Amgen, Inc, Thousand Oaks, CA.
authors.forename: Brian D
authors.initials: BD
authors.lastname: Bradbury
authors.affiliation: Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN; Department of Medicine, University of Minnesota, Minneapolis, MN. Electronic address: acollins@cdrg.org.
authors.forename: Allan J
authors.initials: AJ
authors.lastname: Collins
mesh_terms: D000368:Aged; D000740:Anemia / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D001499:Bayes Theorem; D016001:Confidence Intervals; D019468:Disease Management; D017707:Erythrocyte Transfusion / Q000379:methods / Q000592:standards; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications / Q000453:epidemiology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D015980:Public Health Practice; D006435:Renal Dialysis / Q000009:adverse effects / Q000379:methods / Q000706:statistics & numerical data; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology
keywords: Anemia; Bayesian approach; anemia management; dialysis; end-stage renal disease (ESRD); facility-level practice; standardized ratio; transfusion