Thamer M et al. (2007) Dialysis facility ownership and epoetin dosing in patients receiving hemodialysis. JAMA 297: 1667–1674

Epoetin for anemia management is one of the most costly components of caring for patients with end-stage renal disease. Using the US Renal Data System Medicare claims database, Thamer et al. examined the association between dialysis facility ownership and epoetin dosing in 159,522 patients who received maintenance hemodialysis at 3,982 dialysis centers during a 2-month period in 2004.

The average adjusted dose of epoetin administered was 3,486 U/week greater in for-profit facilities than in nonprofit facilities. At the time of this study, the hematocrit level recommended by the National Kidney Foundation–Kidney Disease Outcome Quality Initiative was 33–36% (hemoglobin 11–12 mg/dl [6.8–7.4 mmol/l]). Patients with a hematocrit level of less than 33% being treated at for-profit facilities received larger epoetin dose increases than did patients with a similarly low hemoglobin level being treated at nonprofit facilities, with the result that fewer patients being treated at for-profit facilities had hematocrit levels below 33%.

Notably, the proportion of patients with hematocrit levels that exceeded the recommended range was higher at for-profit facilities than nonprofit facilities (54% vs 47%). Indeed, patients receiving dialysis at for-profit centers had a mean hematocrit level of 36.2%; the mean at nonprofit centers was 35.6%. The authors conclude that financial incentives and pressure to meet clinical performance targets might encourage dialysis facility staff—particularly those at for-profit centers, at which approximately 80% of US end-stage renal disease patients are treated—to set hematocrit goals that exceed those recommended by clinical guidelines.