The Dialysis Outcomes and Practice Patterns Study released its first DOPPS Practice Monitor (DPM) report since the implementation of the new Prospective Payment System for the End-Stage Renal Disease Program.The DPM data are the first nationally representative, publicly available data to report on dialysis care since PPS implementation, DOPPS reported. The report summarizes preliminary trends for hemodialysis patients overall, and for black versus non-black patients using DPM data between Aug. 2010 and April 2011.
Many practices have remained stable over this time period, including vascular access use, nutrition management, and dialysis treatment time and dose, DOPPS reported. In addition, no substantial trends have been seen to date in clinical outcomes such as mortality and hospitalizations. Changes in the following areas have been observed:
Trends in all patients: From Aug. 2010 to April 2011, average hemoglobin levels fell slightly (0.10 g/dL). The percentage of patients with hemoglobin >12 g/dL declined from 31.4% to 28.0%. The percentage with hemoglobin <10 g/dL rose from 8.5% to 10.0%, and the percentage with hemoglobin <9 g/dL was stable at ~2.7%. The average prescribed epoetin dose fell by ~3% and the average administered dose fell by 6%-7%, with a notable drop in the higher epoetin dose range. The percentage of patients prescribed injectable iron per month rose from 57% to 78%.
Trends by race: Historically, higher epoetin doses have been given to black hemodialysis patients to achieve hemoglobin levels similar to those in non-black patients. Therefore, the new PPS may be expected to affect hemoglobin levels to a greater extent in black patients. Over this reporting period, average hemoglobin levels fell more in blacks than non-blacks (0.23 g/dL versus 0.04 g/dL). The percentage of patients with hemoglobin >12 g/dL fell more in blacks (from 34.7% to 26.9%) than in non-blacks (from 31.0% to 28.5%). The percentage of patients with hemoglobin <10 g/dL rose in blacks (from 8.7% to 11.1%), with little to no change in non-blacks.
Mineral and bone disorder management
Trends in all patients: Overall, the average PTH level rose sharply from 337 to 435 pg/mL from August 2010 to April 2011, an increase of 29%. No substantial changes were seen in serum phosphorus or calcium values. The reasons for the rise in PTH are being investigated; large changes in use of injectable vitamin D or oral medications are not yet apparent.
Trends by race: Black dialysis patients tend to have higher PTH levels and receive higher intravenous vitamin D doses than non-black patients. Over this reporting period, average PTH values rose 29% in black patients and 26% in non-black patients. Very high PTH values (defined here as PTH >600 pg/mL) rose from 17% to 27% in black patients versus 9% to 14% in non-black patients.
DOPPS collects data from representative samples of dialysis facilities in 11 other countries. Early data indicate that the above changes in U.S. dialysis care were not seen in Europe and Japan over the same time. This suggests that the observed changes in the US data may reflect responses to Medicare’s new payment system, rather than trends in care for other reasons.
The next update of the DPM website, in Dec, 2011, will provide data through Aug. 2011.