NCS Research, a research arm of Nephrology Clinical Solutions that is focused on nephrology health care providers, released the results of its Dialysis Anemia Trends survey of 175 dialysis professionals in the United States.
"With the CMS bundle in place, an updated FDA label for ESAs, and continually shifting QIP measures, approaches to anemia management have also shifted with potential implications to the quality of care and management of patients on dialysis," said Alex Yang MD, director of research. "The FDA label states that ESAs should be initiated at hemoglobin levels less than 10 g/dL and ESA doses should be reduced or interrupted at hemoglobin levels approaching or exceeding 11 g/dL." But, Yang says the data from the survey shows nephrologists are targeting lower Hb levels.
"Thirty percent of respondent facilities are using a hemoglobin level less than 10 g/dL as the lower range for target Hb, and 36% are using a hemoglobin level greater than 11 g/dL as the upper range for target Hb. "
Yang also noted that most respondents (88%) reported making ESA dose adjustments on average for each dialysis patient once a month or more frequently, despite the current FDA label that says to avoid frequent dose adjustments. "Additionally, only 15% of respondents believe that more frequent ESA titrations actually reduce Hb excursions," Yang said. "The combination of these two data points prompts the question, ‘Why are we titrating ESAs so frequently when we don’t believe it helps reduce Hb excursions?’
"These apparent disconnects between the guidelines and practice of dialysis anemia management may represent the internal struggle of health care professionals to do what they believe is right for the patient while still adhering to the shifting rules," Yang said.
Following are highlights from the survey:
Current Hb targets and Threshold for ESA hold in U.S. dialysis patients
- 30% of respondent facilities use a hemoglobin less than 10 g/dL as the lower range for target Hb
- 36% of respondent facilities use a hemoglobin greater than 11 g/dL as the upper range for target Hb
- 22% of respondent facilities hold ESA doses at hemoglobin levels of 11 g/dL or less
Frequency of Hb measurements and ESA titrations
- Within in-center dialysis, Hb is measured most frequently twice a month (58%), with 23% once a week and 19% once a month
- In home dialysis, Hb is measured most frequently once a month (72%)
- 88% of respondent facilities are titrating ESA at least once a month or more frequently, representing one or more titrations per patient per month
Beliefs about associations between Hb measurements, ESA titrations, Hb excursions, and total U.S. usage
- Only 14% and 15% of respondents believe that more frequent Hb measurements and more frequent ESA titrations respectively are associated with less frequent Hb excursions (Hb measurements that are outside of the target range) Understand top issues and effective interventions for post-hospitalization anemia
- Top three issues identified with managing post-hospitalization anemia were “Hb decline during hospitalization”, “lack of continuity of care”, and “inadequate dosing strategy”
- Top three effective interventions identified were “coordination of care”, “measure Hb immediately post-hosp”, and “boosting ESA dose post-hospitalization”
The “Dialysis Anemia Trends” Questionnaire was fielded in February 2013 with 175 qualified respondents representing:
- All dialysis organization segments (size and profit status)
- Dialysis facility settings (Free-standing and hospital)
- Dialysis modality (Home and in-center)
- Years of nephrology experience
- Degrees and backgrounds
The analyses described here are selected excerpts from the full report and are presented across all respondents. Other subgroup analyses such as by practice setting, dialysis modality, and size of dialysis organization are not presented. Customized analyses are available upon request, Yang said.