SAN DIEGO—Clinicians are prescribing less erythropoietin and more intravenous iron for anemic hemodialysis patients after the introduction of a prospective payment system (PPS) for dialysis services (“bundling”) and changes to ESA drug labels, according to study findings presented at Kidney Week 2012.

In addition, data point to a trend of declining hemoglobin (Hb) levels in dialysis patients.

Under the PPS, which debuted January 1, 2011, Medicare reimburses dialysis providers with bundled payments that include dialysis-related services and medications that used to be paid for on a free-for-service basis.

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In one study, T. Christopher Bond, PhD, and colleagues at DaVita Clinical Research in Minneapolis, Minn., found that from January 1, 2009 to April 30, 2012, the proportion of patients receiving epoetin alfa (EPO) decreased from 95% to 85%, suggesting an increase in dose holds. Mean EPO doses declined by more than 30,000 units per month. The average dose of IV iron decreased over the study period from 291 to 241 mg per month, but the proportion of patients receiving any IV iron increased from 10% to 14% and the frequency of iron dosing increased from 2.54 doses per patient-month in April 2009 to 2.95 doses per patient-month in April 2012. During the three years of the study, mean Hb levels decreased from 11.6 to 10.8 g/dL. The investigators noted that the effects of the dosing trends are unknown.

Separately, a study led by Richard A. Hirth, PhD, of the University of Michigan School of Public Health in Ann Arbor, demonstrated a substantial decline in ESA use in the months immediately before and after the PPS debuted, whereas the use of iron preparations, which frequently are substituted for ESAs, increased.

Dr. Hirth and his colleagues used Medicare claims data to assess monthly trends during January 2010 to June 2011 for key injectable drugs that were previously bill separately. For 2010, the investigators assessed actual spending; for 2011, they projected spending based on reported utilization.

For ESAs and vitamin D analogues, the biggest changes occurred during the last quarter of 2010, with less expensive vitamin D analogues substituted for more expensive versions, the researchers found. Drug spending fell by $14 per session, nearly three times the mandated reduction in the base payment rate of $5, the researchers reported. The use of peritoneal dialysis increased from 6.45% of dialysis patients in 2010 to 6.8% in 2011, respresenting a break from the flat 2007-2010 trend.  The use of home hemodialysis increased from 1.2% to 1.4%, which represented a continuation of a pre-existing trend.

PPS incentives to increase the use of lower cost treatments have worked, the researchers concluded.

In a separate prospective observational study, John M. Burkart, MD, of Wake Forest University in Winston Salem, N.C., and colleagues analyzed the effect of the PPS on anemia management at small dialysis organizations (50 or fewer facilities) and also found decreased use of ESAs. From the fourth quarter of 2010 to the second quarter of 2011, the median per-administration dose of epoetin alfa fell from 3,472 to 3,240 units and the median per-administration dose of darbepoetin alfa decreased from 56 to 32.5 mcg.

In addition, the proportion of patients with hemoglobin (Hb) levels below 10 g/dL rose from 13% to 17%, a 32% increase. Those with an Hb level above 12 decreased from 29% to 19%, a 36% decline.