title: The economic impact of improving phosphate binder therapy adherence and attainment of guideline phosphorus goals in hemodialysis patients: a Medicare cost-offset model.
abstract: BACKGROUND
  Hyperphosphatemia (serum phosphorus >5.5 mg/dL) in hemodialysis patients is a key factor in mineral and bone disorders and is associated with increased hospitalization and mortality risks. Treatment with oral phosphate binders offers limited benefit in achieving target serum phosphorus concentrations due to high daily pill burden (7-10 pills/day) and associated poor medication adherence. The economic value of improving phosphate binder adherence and increasing percent time in range (PTR) for target phosphorus concentrations has not been previously assessed in dialysis patients. The current retrospective analysis was conducted to summarize health care cost savings to United States (US) payers associated with improved phosphate binder adherence and increased PTR for target phosphorus concentrations in adult end-stage renal disease (ESRD) patients receiving hemodialysis therapy.
  
  
  METHODS
  Phosphate binder adherence and PTR were derived from hemodialysis patients who were treated at a large dialysis organization between January 2007 and December 2011. Cost model inputs were derived from US Renal Data System data between July 2007 and December 2009. A cost-offset model was constructed to estimate monthly and annual incremental health care costs (total Medicare; inpatient, outpatient, and Medicare Part B) associated with different levels of phosphate binder adherence and PTR. Model inputs included number of ESRD patients, population adherence to phosphate binders, PTR associated with adherence to phosphate binders, and per-patient per-month cost associated with PTR. A base case model estimated monthly and annual costs of phosphate binder therapy in the population using estimated model inputs. The estimated adherence rate was used to determine number of patients in compliant and noncompliant groups. Monthly costs were calculated as the sum of per-patient per-month cost times the number of patients in adherent and nonadherent groups. Annual costs were monthly costs times 12 and assumed the same level of adherence, PTR, and per-patient per-month costs over time. To study the impact of improving phosphate binder adherence and PTR on cost outcomes, we hypothetically and simultaneously increased both base phosphate binders adherence and PTR for adherent patients (adherence/PTR: 10/20%, 20/40%, 30/60%). Monthly and annual costs were derived for each scenario and compared against the results of the base case model. One-way sensitivity analysis was performed to test model robustness.
  
  
  RESULTS
  The base case model estimated total Medicare and inpatient costs of $5,152,342 and $1,435,644, respectively (N = 1,000). When base case model costs were compared to results of each extended model scenario, overall Medicare cost savings (range 0.3-1.9%) and inpatient cost savings (range 1.2-5.7%) were observed. The one-way sensitivity analysis indicated that results were sensitive to PTR for adherent and nonadherent patients and the factor used to increase adherence rate and PTR associated with adherence in the hypothetical scenarios. However, cost savings in overall Medicare costs and inpatient costs were still noted.
  
  
  CONCLUSIONS
  Increasing phosphate binder adherence and improving phosphorus control were associated with increased cost savings in total Medicare costs and inpatient costs.
authors.affiliation: DaVita Clinical Research, 825 South 8th Street, Minneapolis, MN, 55404, USA.
authors.forename: Karthik
authors.initials: K
authors.lastname: Ramakrishnan
authors.forename: Peter
authors.initials: P
authors.lastname: Braunhofer
authors.forename: Britt
authors.initials: B
authors.lastname: Newsome
authors.forename: Deborah
authors.initials: D
authors.lastname: Lubeck
authors.forename: Steven
authors.initials: S
authors.lastname: Wang
authors.forename: Jennifer
authors.initials: J
authors.lastname: Deuson
authors.forename: Ami J
authors.initials: AJ
authors.lastname: Claxton
mesh_terms: D000328:Adult; D002614:Chelating Agents / Q000627:therapeutic use*; D017046:Cost Savings; D005260:Female; D017048:Health Care Costs; D006801:Humans; D054559:Hyperphosphatemia / Q000097:blood / Q000188:drug therapy / Q000191:economics / Q000209:etiology; D007676:Kidney Failure, Chronic / Q000628:therapy; D008297:Male; D006278:Medicare / Q000191:economics; D010710:Phosphates / Q000097:blood*; D010758:Phosphorus / Q000097:blood*; D017410:Practice Guidelines as Topic; D006435:Renal Dialysis / Q000009:adverse effects / Q000191:economics; D012189:Retrospective Studies; D014481:United States; D016903:Drug Monitoring
chemical_list: D002614:Chelating Agents; D010710:Phosphates; D010758:Phosphorus