The Dialysis Outcomes and Practice Patterns Study (DOPPS) practice monitor (DPM) is showing several apparent practice changes related specifically to mineral and bone disorder management in dialysis patients.
DOPPS has seen continued evidence from several dialysis facilities of increased oral active vitamin D (calcitriol) prescription within a 3-month period (from 6% in April 2014 to 24% in April 2015, overall). Concurrently, DOPPS has observed a decline in use of IV active vitamin D or analog products. Use of active vitamin D therapy overall has remained fairly stable, which suggests substitution of oral calcitriol in place of IV therapies.
Preliminary data suggest an increase in serum parathyroid hormone (PTH) levels and a decline in serum calcium levels among facilities switching from IV to oral vitamin D therapy that are not observed in other DPM facilities. This change in practice is consistent with current incentives under the ESRD bundled payment system (2011), in which IV medications are not separately billable by dialysis providers. This change may also reflect the addition of hypercalcemia (>10.2mg/dl) as a measure in both the 2016 Quality Incentive Program (QIP; released in November 2013) and the CMS Dialysis Facility Compare star rating system (released in January 2015).
DOPPS will hold a web conference on the latest DPM update with a focus on measures related to the CMS Dialysis Facility Compare star rating system on Wednesday, September 9 at 3 p.m. Registration is now open.
Mean serum PTH levels overall increased from 331 pg/ml in August 2010 to 428 pg/ml in April 2011 before stabilizing in 2012 and 2013. However, mean serum PTH levels have increased again, from 426 pg/ml in January 2014 to 487 pg/ml in April 2015. PTH levels now exceed 600 pg/ml in 16% of non-black and 32% of black patients. PTH levels ≥600 pg/ml have been consistently associated with adverse clinical outcomes in observational studies..
Future monitoring of these trends is warranted. Trends should be confirmed with national data, when available, and their effect on clinical outcomes understood.
The DPM continues to provide graphics demonstrating large facility-level variation in risks of transfusion and hospitalization recorded in Medicare claims data. For example, in July 2013 the facility percentage of patients transfused over the next six months ranged from 4% or lower (10th percentile of facilities) to 18% or higher (90th percentile of facilities), a five-fold variation.
About The Dialysis Outcomes and Practice Patterns Study (DOPPS) Practice Monitor (DPM) reports more than 1,500 regularly updated charts, figures, and data tables. Emerging trends in US hemodialysis (HD) practice through April 2015, based on a national sample of US dialysis facilities, are included in the latest DPM update at DOPPS.org/DPM.