title: Has dialysis payment reform led to initial racial disparities in anemia and mineral metabolism management?
abstract: Implementation of the Medicare ESRD prospective payment system (PPS) and changes to dosing guidelines for erythropoiesis-stimulating agents (ESAs) in 2011 appear to have influenced use of injectable medications among dialysis patients. Given historically higher ESA and vitamin D use among black patients, we assessed the effect of these policy changes on racial disparities in the management of anemia and mineral metabolism. Analyses used cross-sectional monthly cohorts for a period-prevalent sample of 7384 maintenance hemodialysis patients at 132 facilities from the Dialysis Outcomes and Practice Patterns Study (DOPPS) Practice Monitor. Linear splines with knots at each policy change were used in survey-weighted regressions to estimate time trends in hemoglobin (Hgb), erythropoietin (EPO) dose, intravenous (IV) iron dose, ferritin, transferrin saturation (TSAT) concentration, parathyroid hormone (PTH), IV vitamin D dose, cinacalcet use, and phosphate binder use. From August 2010 to December 2011, mean Hgb declined from 11.5 to 11.0 g/dl (P<0.001), mean EPO dose declined from 20,506 to 14,777 U/wk (P<0.001), and mean serum PTH increased from 340 to 435 pg/ml (P<0.001). No meaningful differences by race were observed regarding the rates of change of management practices or laboratory measures (all P>0.21). Mean EPO and vitamin D dose and serum PTH levels remained higher in blacks. Despite evidence that anemia and mineral metabolism management practices have changed significantly over time, there was no immediate indication of racial disparities resulting from implementation of the PPS or ESA label change. Further studies are needed to examine effects among patient and facility subgroups.
authors.affiliation: Arbor Research Collaborative for Health, Ann Arbor, Michigan; Marc.Turenne@ArborResearch.org.
authors.forename: Marc N
authors.initials: MN
authors.lastname: Turenne
authors.affiliation: Arbor Research Collaborative for Health, Ann Arbor, Michigan;
authors.forename: Elizabeth L
authors.initials: EL
authors.lastname: Cope
authors.affiliation: Arbor Research Collaborative for Health, Ann Arbor, Michigan; Catholic Health East/Trinity Health, Livonia, Michigan; and.
authors.forename: Shannon
authors.initials: S
authors.lastname: Porenta
authors.affiliation: Arbor Research Collaborative for Health, Ann Arbor, Michigan;
authors.forename: Purna
authors.initials: P
authors.lastname: Mukhopadhyay
authors.affiliation: Arbor Research Collaborative for Health, Ann Arbor, Michigan;
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Fuller
authors.affiliation: Arbor Research Collaborative for Health, Ann Arbor, Michigan;
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Pearson
authors.affiliation: Arbor Research Collaborative for Health, Ann Arbor, Michigan; University of Michigan, Ann Arbor, Michigan.
authors.forename: Claudia
authors.initials: C
authors.lastname: Dahlerus
authors.affiliation: Arbor Research Collaborative for Health, Ann Arbor, Michigan; University of Michigan, Ann Arbor, Michigan.
authors.forename: Brett
authors.initials: B
authors.lastname: Lantz
authors.affiliation: Arbor Research Collaborative for Health, Ann Arbor, Michigan;
authors.forename: Francesca
authors.initials: F
authors.lastname: Tentori
authors.affiliation: Arbor Research Collaborative for Health, Ann Arbor, Michigan;
authors.forename: Bruce M
authors.initials: BM
authors.lastname: Robinson
mesh_terms: D001741:Black or African American / Q000706:statistics & numerical data*; D000368:Aged; D000740:Anemia / Q000209:etiology / Q000517:prevention & control; D003430:Cross-Sectional Studies; D005260:Female; D054625:Healthcare Disparities; D006397:Hematinics / Q000008:administration & dosage; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications* / Q000191:economics / Q000208:ethnology; D008297:Male; D008875:Middle Aged; D011445:Prospective Payment System; D063505:Racism; D012044:Regression Analysis; D006435:Renal Dialysis / Q000191:economics*; D014481:United States / Q000453:epidemiology
chemical_list: D006397:Hematinics
keywords: ESRD; anemia; dialysis; erythropoietin; mineral metabolism; parathyroid hormone