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The DOPPS Practice Monitor for US Dialysis Care: Trends Through April 2011

2011; Elsevier BV; Volume: 59; Issue: 2 Linguagem: Inglês

10.1053/j.ajkd.2011.11.005

1523-6838

Bruce Robinson, Douglas S. Fuller, Brian Bieber, Marc Turenne, Ronald L. Pisoni,

Chronic Kidney Disease and Diabetes

More than 380,000 people receive maintenance dialysis for the treatment of end-stage kidney failure in the United States. In 2008, Medicare expenditures for dialysis patients totaled $22 billion, or 4.8% of the total Medicare budget.1US Renal Data SystemUSRDS 2011 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2011Google Scholar The new end-stage renal disease prospective payment system (PPS), a program begun by the US Centers for Medicare & Medicaid Services in January 2011, is intended to control dialysis costs through bundled payments (that is, fewer dialysis-related medications and services are now separately billable). The Quality Incentive Program, beginning in 2012 with the evaluation of dialysis unit clinical data collected in 2010, is the first Medicare program that ties provider or facility payments to performance, as defined by meeting particular quality measures. The Dialysis Outcomes and Practice Patterns Study (DOPPS) Practice Monitor (DPM) is an initiative of the DOPPS. It is based on a national sample of US hemodialysis patients that provides the first nationally representative data, publicly available on the DPM website, to report trends in dialysis care from before to after implementation of this new bundled PPS. DPM reports comprise more than 800 regularly updated charts, figures, and data tables that can be viewed at the DPM website (www.dopps.org/DPM). The DPM sample provides comparisons and trends over time for the United States as a whole and examines patient subgroups and facility types. An article describing DPM methods has been published recently.2Robinson B.M. Fuller D. Zinsser D. et al.The Dialysis Outcomes and Practice Patterns Study (DOPPS) Practice Monitor: rationale and methods for an initiative to monitor the new US bundled dialysis payment system.Am J Kidney Dis. 2011; 57: 822-831Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar In this first overview of DPM findings for AJKD, which covers data through April 2011, we summarize preliminary trends overall and additionally focus on specific patient groups. Data reflect an average of 3,502 hemodialysis patients in 93 facilities per month and are weighted estimates based on the full study sample; generally comparable trends have been found when restricted to facilities participating at all times, when the data are not weighted, and under a variety of other assumptions. Many clinical practices have remained fairly stable from August 2010 through April 2011. These practices include dialysis treatment time and dose, nutrition management, and others. Moreover, the data through April 2011 do not show substantive trends in major clinical outcomes, such as mortality and hospitalization rates. Because payment for injectable dialysis-related medications and their oral equivalents is now bundled within the PPS, many have expected changes in the management of anemia and mineral and bone disorder. Below, we summarize our observations regarding these 2 areas of patient care. Average hemoglobin levels decreased slightly (by 0.10 g/dL) from August 2010 to April 2011 (Fig 1A), with the largest decrease between November 2010 and February 2011. The percentage of patients with hemoglobin levels >12 g/dL decreased from 31.4% to 28.0%. Concurrently, the percentage of patients with hemoglobin levels <10 g/dL increased from 8.5% to 10.0%, whereas the proportion with hemoglobin levels <9 g/dL was stable at ∼2.7%. The mean prescribed erythropoietin dose decreased by ∼3%, and the average administered dose decreased by 6%-7%, with the most notable decrease occurring in the higher erythropoietin dose ranges (12% and 13% decrease from baseline for the 90th and 95th percentiles, respectively). The percentage of patients with intravenous iron prescribed per month increased from 57% to 78%. Mean serum parathyroid hormone (PTH) level increased sharply from 337 to 435 pg/mL between August 2010 and April 2011, an increase of 29% (Fig 1B). This trend appeared relatively linear from September 2010 onward. No clinically meaningful changes were seen in serum phosphorus or calcium values. Reasons for the increase in PTH level are being investigated; large changes in the use of injectable vitamin D or oral medications are not yet apparent. We evaluated data from earlier than August 2010 to check whether changes in hemoglobin and PTH levels were recent, rather than a continuation of prior trends. Evaluation of May 2010 to April 2011 data for facilities enrolling early in the DPM (averaging 2,052 patients/mo) confirmed that hemoglobin levels generally were stable from May to November 2010 and PTH levels remained relatively steady from May to September 2010. In addition to tracking nationwide trends, we are focusing on trends in patient groups highlighted in the 2010 US Government Accountability Office report3US Government Accountability OfficeEnd-Stage Renal Disease: CMS Should Monitor Access to and Quality of Dialysis Care Promptly After Implementation of New Bundled Payment System. US Government Accountability Office, Washington, DC2010Google Scholar as being especially likely to experience changes in care with the PPS and the Quality Incentive Program, largely reflecting above-average dialysis costs (including higher doses of erythropoietin and intravenous vitamin D analogues). These groups include African Americans, dual-coverage Medicare/Medicaid recipients, and younger patients. We summarize preliminary findings for African American patients (30.5% of sample), Medicaid beneficiaries (27.9%), and individuals younger than 55 years (27.8%). During this reporting period, mean hemoglobin levels decreased more in African Americans than in others (0.23 vs 0.04 g/dL; P < 0.05 in models with and without adjustment for age and Medicaid status; Fig 2) . The percentage of patients with hemoglobin levels >12 g/dL decreased more in African Americans (from 34.7% to 26.9%) than in others (from 31.0% to 28.5%; P = 0.04 for unadjusted difference in trend), whereas the percentage of patients with hemoglobin levels <10 g/dL increased in African Americans (from 8.7% to 11.1%), with little to no change in others (P = 0.1). Although the percentage of patients with hemoglobin levels 600 pg/mL) increased to a greater extent in African Americans (from 17% to 27%) versus others (from 9% to 14%). Temporal trends in care may occur for other reasons, such as publication of key research findings, regulatory changes, or release of new practice guidelines. The DOPPS annual report4Arbor Research Collaborative for Health2010 Annual Report of the Dialysis Outcomes and Practice Patterns Study: hemodialysis data 1999-2008.http://www.dopps.org/annualreportGoogle Scholar provides data from representative samples of dialysis facilities in 11 other countries, allowing us to evaluate for secular trends for other reasons. Early data indicate that the changes in US dialysis care described here did not occur in other countries tracked by the DOPPS during the same period. Despite the landmark reform to US dialysis payment with PPS implementation in January 2011, many practices have changed little during this early transition period, and we have seen no early trends in clinical event rates. The most notable findings early in the expanded bundle era include a decrease in average hemoglobin levels and a substantial increase in PTH levels. There has been a notable decrease in erythropoietin doses at the higher end of the dose range, as well as an overall increase in intravenous iron use. Large changes in the use of intravenous vitamin D or oral mineral and bone disorder medications are not yet apparent. In response to the 2010 Government Accountability Office report suggesting a focus on higher cost populations, the most notable difference to date is a larger decrease in average hemoglobin levels in African American versus other patients. Reasons for the observed differences by race, such as the role of facility characteristics (eg, racial mix, payer mix, facility size and location), require investigation. Future monitoring of these trends, confirmation with national data when eventually available, and understanding their effect on clinical outcomes, if any, are warranted. Additional DPM graphics, underlying data tables, and trends by facility characteristics, such as dialysis organization size, are provided at the DPM website, which is updated on a bimonthly basis. Support: The DOPPS is administered by the nonprofit Arbor Research Collaborative for Health of Ann Arbor, MI, and is supported by scientific grants from Amgen (since 1996), Kyowa Hakko Kirin (since 1999, in Japan), Genzyme and Abbott (both since 2009), and Baxter (since 2011), without restrictions on publications. Financial Disclosure: Dr Robinson has received a speaker's fee from Kyowa Hakko Kirin. Dr Pisoni has served as a consultant for Takeda and has received speaker fees from Kyowa Hakko Kirin and Vifor. The remaining authors declare that they have no other relevant financial interests.